Percutaneous Closure of Post Myocardial Infarction Ventricular Septal Rupture in an Unstable Hemodynamic State, Using an Unconventional Internal Jugular venous access;

We report a 56-year-old woman with multiple cardiovascular risk factors who initially present with chest discomfort. She underwent successful primary percutaneous coronary intervention (PCI) on left anterior descending and right coronary artery . Few hours later and after the hemodynamic deterioration of patient,

High Central Venous Pressure after Cardiac Surgery Might Depict Hemodynamic Deterioration Associated with Increased Morbidity and Mortality

Background: Cardiac surgery patients represent a high-risk cohort in intensive care units (ICUs). Central venous pressure (CVP) measurement seems to remain an integral part in hemodynamic monitoring, especially in cardio-surgical ICUs. However, its value as a prognostic marker for organ failure is still unclear. Therefore, we analyzed postoperative CVP values after adult cardiac surgery in a large cohort with regard to its prognostic value for morbidity and mortality. Methods: All adult patients admitted to our ICUs between 2006 and 2019 after cardiac surgery were eligible for inclusion in the study (n = 11,198). We calculated the median initial CVP (miCVP) after admission to the ICU, which returned valid values for 9802 patients. An ROC curve analysis for optimal cut-off miCVP to predict ICU mortality was conducted with consecutive patient allocation into a (a) low miCVP (LCVP) group (≤11 mmHg) and (b) high miCVP (HCVP) group (>11 mmHg). We analyzed the impact of high miCVP on morbidity and mortality by propensity score matching (PSM) and logistic regression. Results: ICU mortality was increased in HCVP patients. In addition, patients in the HCVP group required longer mechanical ventilation, had a higher incidence of acute kidney injury, were more frequently treated with renal replacement therapy, and showed a higher risk for postoperative liver dysfunction, parametrized by a postoperative rise of ≥ 10 in MELD Score. Multiple regression analysis confirmed HCVP has an effect on postoperative ICU-mortality and intrahospital mortality, which seems to be independent. Conclusions: A high initial CVP in the early postoperative ICU course after cardiac surgery is associated with worse patient outcome. Whether or not CVP, as a readily and constantly available hemodynamic parameter, should promote clinical efforts regarding diagnostics and/or treatment, warrants further investigations.

The incidence of myopericarditis in patients with COVID-19

Introduction: SARS-COV-2 can affect different organ systems, including the cardiovascular system with wide spectrum of clinical presentations including the thrombotic complications, acute cardiovascular injury and myopericarditis. There is limited study regarding COVID-19 and myopericarditis. The aim of this study was to evaluate myopericarditis in patients with definite diagnosis of COVID-19. Methods: In this observational study we analyzed the admitted patients with definite diagnosis of COVID-19 based on positive RT-PCR test. Laboratory data, and ECG changes on days 1-3-5 were analyzed for sign of pericarditis and also QT interval prolongation. Echocardiography was performed on days 2-4 and repeated as necessary, and one month after discharge for possible late presentation of symptom. Any patient with pleuritic chest pain, and pericardial effusion and some rise in cardiac troponin were considered as myopericarditis. Results: A total of 404 patients (18-90 years old, median =63, 273 males and 131 females) with definite diagnosis of COVID-19 were enrolled in the study. Five patients developed in-hospital pleuritic chest pain with mild left ventricular dysfunction and mild pericardial effusion and diagnosed as myopericarditis, none of them proceed to cardiac tamponade. We found no case of late myopericarditis. Conclusion: Myopericarditis, pericardial effusion and cardiac tamponade are rare complication of COVID-19 with prevalence about 1.2 %, but should be considered as a possible cause of hemodynamic deterioration.

Validation of an Automatic Tagging System for Identifying Respiratory and Hemodynamic Deterioration Events in the Intensive Care Unit

Objectives: Predictive models for critical events in the intensive care unit (ICU) might help providers anticipate patient deterioration. At the heart of predictive model development lies the ability to accurately label significant events, thereby facilitating the use of machine learning and similar strategies. We conducted this study to establish the validity of an automated system for tagging respiratory and hemodynamic deterioration by comparing automatic tags to tagging by expert reviewers.Methods: This retrospective cohort study included 72,650 unique patient stays collected from Electronic Medical Records of the University of Massachusetts’ eICU. An enriched subgroup of stays was manually tagged by expert reviewers. The tags generated by the reviewers were compared to those generated by an automated system.Results: The automated system was able to rapidly and efficiently tag the complete database utilizing available clinical data. The overall agreement rate between the automated system and the clinicians for respiratory and hemodynamic deterioration tags was 89.4% and 87.1%, respectively. The automatic system did not add substantial variability beyond that seen among the reviewers.Conclusions: We demonstrated that a simple rule-based tagging system could provide a rapid and accurate tool for mass tagging of a compound database. These types of tagging systems may replace human reviewers and save considerable resources when trying to create a validated, labeled database used to train artificial intelligence algorithms. The ability to harness the power of artificial intelligence depends on efficient clinical validation of targeted conditions; hence, these systems and the methodology used to validate them are crucial.

Inadvertent Right Ventricle Perforation by Temporary Pacemaker Lead: A Case Report Requiring Surgical Exploration

Right ventricle perforation by pacemaker lead is rare but a life-threatening complication. It may present acutely within few hours of pacemaker implantation as hemopericardium, dreaded cardiac tamponade, leading to acute hemodynamic deterioration; even death, if not address immediately. At times, it presents gradually with progressive decline in hemodynamic and requires surgical exploration.The authors report a case of 51-year old female whose hemodynamic worsens gradually after temporary pacemaker implantation, requiring surgical exploration.

Giant Right Ventricular Fibroma: Prenatal Diagnosis and Partial Resection in Early Infancy

Congenital cardiac fibromas are very rare and prenatal diagnosis has been reported in just a few cases. We describe a four-month-old infant presenting a symptomatic giant right ventricular fibroma discovered during prenatal scanning at 33 weeks of gestation, which was confirmed after delivery on echocardiogram and cardiac magnetic resonance imaging. Due to progressive hemodynamic deterioration, partial surgical resection was performed and the patient recovered uneventfully. We report the successful management during early infancy of a giant cardiac fibroma prenatally diagnosed.

Subarachnoid Hemorrhage and Extracorporeal Blood Purification with HA-380 and High-Volume Hemofiltration: A New Therapeutic Challenge at the Neurocritical Care Unit? A Case Report

We present the case of a patient with subarachnoid hemorrhage (SAH) secondary to a ruptured cerebral aneurysm and a refractory shock with high doses of vasopressors without a proven source of infection. This patient received therapy with high-volume hemofiltration plus adsorption, resolving the hemodynamic deterioration and with good neurological evolution. Our clinical case proposes that extracorporeal therapies may have a feasibility role in the management of complications of SAH.

Percutaneous catheter-directed treatment in intermediate-high risk acute pulmonary embolism. Hemodynanical and right heart function-related parameters changes and short-term outcomes

Funding Acknowledgements Type of funding sources: None. Introduction Acute pulmonary embolism (PE) is the third cause of cardiovascular mortality, right after acute myocardial infarction and stroke. Systemic thrombolytic therapy (SLT) restores pulmonary perfusion earlier than low molecular-weight heparin, but with a significantly higher risk of major bleeding. Currently, in our area there is a lack of standardized protocols for the management of patients in which SLT is contraindicated. Objective The purpose of our study was to evaluate the safety and efficacy of percutaneous catheter-directed treatment (PCT) for high-intermediate risk PE (HIRPE) patients with hemodynamic deterioration on anticoagulation treatment. Methods We consecutively included all patients with HIRPE patients who underwent PCT in our center. Before and after PCT clinical, echocardiographic and hemodynamic variables were collected, as well as events (major or minor bleeding, death) during follow-up. Results From February 2018 to February 2020, 20 patients with HIRPE underwent PCT. The mean age of our cohort was 62 (52 - 73), and 46.6% were women. The indication for PCT was absolute contraindication for SLT (9 patients, 45%), followed by high bleeding risk (8 patients, 40%) and failure of SLT. Vascular access was mainly performed through femoral vein (12 patients, 60%) followed by a peripheral vein of the superior limb (8 patients, 40%). During pulmonary angiography, lobar arteries occlusion was observed in 60% of the cases, with involvement of main pulmonary arteries in 40% of the cases. Local thrombolysis with Alteplase was performed in 17 cases (85%), and in 8 cases it was decided to carry-out a thrombus fragmentation-aspiration strategy. We observed and early improvement of hemodynamic parameters after PCT, with a significant reduction of mean pulmonary artery pressure before and after PCT (40 +/- 13 mmHg vs. 25 +/- 12 mmHg, p < 0.001, figure 1), as well as an improvement in systolic blood pressure (102 +/- 13 mmHg vs. 129 +/- 14, p < 0.001) and the partial pressure of oxygen (51 +/- 3 vs. 67 +/- 2, p = 0.002). We also observed a significant decrease in NT-proBNP values at admission and 48 hours after PCT (4791 +/- 1077 pg/mL vs. 2311 +/- 680 pg/mL, p = 0.002, figure 2), as well as an improvement in echocardiographic right ventricular function parameters evaluated at admission and 72 hours after PCT, such as TAPSE (15 +/- 2 mm vs 22 +/- 3 mm, p = 0.001) or right ventricle basal diameter (51 +/- 4 mm vs. 41 +/- 2 mm, p = 0.001). During a median follow-up of 7 months (4 - 12 months) one patient died of non-cardiac cause and none of them had a major or minor bleeding event. Conclusion PCT in patients with HIRPE with hemodynamic deterioration on anticoagulation is a simple and effective procedure with an immediate reduction of mean pulmonary pressure and an early improvement of right ventricle-related biochemical, hemodynamic and echocardiographic parameters. Abstract Figure 1: mPAP after and before PCT.

Close linkage between blood total ketone body levels and B-type natriuretic peptide levels in patients with cardiovascular disorders

In patients with cardiovascular disorders, blood total ketone body (TKB) levels increase with worsening heart failure and are consumed as an alternative fuel to fatty acid and glucose. We investigated factors contributing to the increase in the blood TKB levels in patients with cardiovascular disorders. The study population consisted of 1030 consecutive patients who underwent cardiac catheterization. Covariance structure analyses were performed to clarify the direct contribution of hemodynamic parameters, including the left ventricular end-diastolic pressure (LVEDP), left ventricular end-systolic volume index (LVESVI), left ventricular end-diastolic volume index (LVEDVI), and B-type natriuretic peptide (BNP) levels, to TKB by excluding other confounding factors. These analyses showed that the TKB levels were significantly associated with the BNP level (P = 0.003) but not the LVEDP, LVESVI, or LVEDVI levels. This was clearly demonstrated on a two-dimensional contour line by Bayesian structure equation modeling. The TKB level was positively correlated with the BNP level, but not LVEDP, LVESVI or LVEDVI. These findings suggested that elevated blood TKB levels were more strongly stimulated by the increase in BNP than by hemodynamic deterioration. BNP might induce the elevation of TKB levels for use as an important alternative fuel in the failing heart.