Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort

Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE × US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation–SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE × US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE × US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE × US score, should be further studied before expanding its use in AHF patients.

Pacemaker Implantation Via Femoral Vein and Successful Arrhythmia Management in an Elderly Patient with Fontan Circulation: A Case Report

Background The frequency of arrhythmias increases after the Fontan operation over time; atrial tachycardia (AT) and sinus node dysfunction (SND) are frequently observed. Case summary Our patient was 63-year-old woman who underwent a lateral tunnel Fontan operation for double outlet right ventricle at age 36. She experienced paroxysmal AT for one year, and antiarrhythmic medication was not feasible due to symptomatic SND. Computed tomography revealed a 45 mm-sized thrombus in the high right atrium (RA). The patient had three coexisting conditions: paroxysmal AT, symptomatic SND and the RA thrombus, for which total cavopulmonary connection conversion and epicardial PMI would have been effective; however, given her age and comorbidities, surgical treatment was considered high-risk. Catheter ablation was avoided because of the RA thrombus. Finally, a transvenous pacemaker was implanted via the right femoral vein to avoid the RA thrombus and severe venous tortuosity from the left subclavian vein to the RA. After PMI, the patient was prescribed amiodarone and bisoprolol for AT suppression. AT occurred once in the third month after discharge. We increased the dose of amiodarone, and she has been tachycardia-free. Discussion Transvenous PMI must be considered in cases where open thoracic surgery or catheter ablation cannot be performed. This is the first report of transvenous PMI via the right femoral vein and successful AT and SND management in an elderly Fontan patient.

High incidence of large bore temporary hemodialysis catheter malfunction in patients with COVID-19 related kidney injury

Purpose: To evaluate the incidence of large bore hemodialysis catheter malfunction in the setting of COVID-19. Materials and methods: A retrospective review was performed of all patients who underwent placement of a temporary hemodialysis catheter after developing kidney injury after COVID-19 infection at our institution. Data collected included demographic information, procedure related information, and incidence of replacement due to lumen thrombosis. Groups were compared using students t-test for continuous variables and Fisher’s exact test for nominal variables. Results: Sixty-four patients (43M, mean age 63.2 ± 13.3) underwent placement of temporary hemodialysis catheter placement for kidney injury related to COVID 19 infection. Thirty-one (48.4%) of catheters were placed via an internal jugular vein (IJV) access and 33 (52.6%) of catheters were placed via a common femoral vein (CFV) access. Overall, 15 (23.4%) catheters required replacement due to catheter dysfunction. There were no differences in demographics in patients who required replacement to those who did not ( p > 0.05). Of the replacements, 5/31 (16%) were placed via an IJV access and 10/33 (30.3%) were placed via a CFV access ( p = 0.18). The average time to malfunction/replacement was 7.8 ± 4.8 days for catheters placed via an IJ access versus 3.4 ± 3.3 days for catheters placed via a CFV access ( p = 0.055). Conclusion: A high incidence of temporary dialysis catheter lumen dysfunction was present in patients with COVID-19 infection. Catheters placed via a femoral vein access had more frequent dysfunction with shorter indwelling time.

Incomplete Removal and Accidental Retention of Temporary Epicardial Pacing Wires in the Chest after Heart Surgery: A Case Report

Temporary pacemaker wires are commonly used for the diagnosis and treatment of arrhythmias in the acute postoperative period. We herein describe a 65-year-old woman with a history of coronary artery bypass graft surgery who was referred to the hospital with a purulent discharge in the lower third of the sternal region while on antibiotics. Two years later, following treatment failure, 2 sternal wires were removed. Several years after the surgery, the patient developed a purulent discharge. On suspicion of rib osteomyelitis, the last left cartilage attached to the sternum was excised and removed together with an infectious tract. During the operation, the right ventricle was torn, and tampons were used to control bleeding. The patient was placed under cardiopulmonary bypass via the cannulation of the left femoral artery and the right femoral vein. The sternum was opened, and the rupture site was repaired. A temporary epicardial pacing wire was found at the site of the right ventricular rupture. Several days later, the patient was taken from the intensive care unit to the operating room due to a pulsatile hematoma in the left groin and a diagnosis of a pseudoaneurysm of the femoral artery. After a week, the purulent discharge at the lower sternum improved, and the patient was discharged. At 1 month’s post-discharge follow-up, the infection was eradicated

Venous cystic adventitial disease: to cure or manage? A case series

Venous cystic adventitial disease is a rare vascular condition that can have significant effects on a patient’s quality of life. The clinical presentation of venous cystic adventitial disease is variable, and there are no established guidelines on investigation or treatment of the disease. We present a series of three patients with venous cystic adventitial disease of the common femoral vein, treated within a single vascular surgery unit. Each of the three patients presented within 18 months of each other, despite the rarity of the disease. These are the only known cases treated within this vascular surgery unit. The investigation, management and treatment of each patient are individualised, with a management focus on quality of life.

Percutaneous Retrieval of a Fragmented Port-a-Cath With the Snaring Technique

Background: Long-term use of central venous catheters is common in cancer patients for chemotherapy. The remaining of these catheters after the end of the treatment period can be associated with complications such as thrombosis and catheter fragmentation. Case Report: This report presents a 42-year-old woman with a history of colon cancer whose inner part of the vascular access was detached from the outer part after removing the central venous catheter, and the catheter remained inside the internal jugular vein. After preparing the patient’s chest X-ray, the catheter was removed from the femoral vein by percutaneous retrieval and successfully taken out using the snaring technique. Conclusion: Overall, percutaneous retrieval is a safe way to remove intravascular foreign bodies that can prevent major surgical complications.

Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV) to predict fluid responsiveness in critically ill patients. Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 21 October 2021). The number of true positives, false positives, false negatives, and true negatives for the index test to predict fluid responsiveness was collected. We used a hierarchical summary receiver operating characteristics model and bivariate model for meta-analysis. Finally, 30 studies comprising 1719 patients were included in this review. The ultrasonographic variation of the IVC showed a pooled sensitivity and specificity of 0.75 and 0.83, respectively. The area under the receiver operating characteristics curve was 0.86. In the subgroup analysis, there was no difference between patients on mechanical ventilation and those breathing spontaneously. In terms of the IJV, SCV, and FV, meta-analysis was not conducted due to the limited number of studies. The ultrasonographic measurement of the variation in diameter of the IVC has a favorable diagnostic accuracy for predicting fluid responsiveness in critically ill patients. However, there was insufficient evidence in terms of the IJV, SCV, and FV.

AI-Enabled, Ultrasound-Guided Handheld Robotic Device for Femoral Vascular Access

Hemorrhage is a leading cause of trauma death, particularly in prehospital environments when evacuation is delayed. Obtaining central vascular access to a deep artery or vein is important for administration of emergency drugs and analgesics, and rapid replacement of blood volume, as well as invasive sensing and emerging life-saving interventions. However, central access is normally performed by highly experienced critical care physicians in a hospital setting. We developed a handheld AI-enabled interventional device, AI-GUIDE (Artificial Intelligence Guided Ultrasound Interventional Device), capable of directing users with no ultrasound or interventional expertise to catheterize a deep blood vessel, with an initial focus on the femoral vein. AI-GUIDE integrates with widely available commercial portable ultrasound systems and guides a user in ultrasound probe localization, venous puncture-point localization, and needle insertion. The system performs vascular puncture robotically and incorporates a preloaded guidewire to facilitate the Seldinger technique of catheter insertion. Results from tissue-mimicking phantom and porcine studies under normotensive and hypotensive conditions provide evidence of the technique’s robustness, with key performance metrics in a live porcine model including: a mean time to acquire femoral vein insertion point of 53 ± 36 s (5 users with varying experience, in 20 trials), a total time to insert catheter of 80 ± 30 s (1 user, in 6 trials), and a mean number of 1.1 (normotensive, 39 trials) and 1.3 (hypotensive, 55 trials) needle insertion attempts (1 user). These performance metrics in a porcine model are consistent with those for experienced medical providers performing central vascular access on humans in a hospital.