Constrictive pericarditis in the setting of repeated chest trauma in a mixed martial arts fighter

Background Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium. This case demonstrates that mixed martial arts (MMA) is a previously unrecognized risk factor for CP, diagnosis of which is supported by cardiac imaging, right and left heart catheterization, and histological findings of dense fibrous tissue without chronic inflammation. Case presentation A 47-year-old Caucasian male former mixed martial arts (MMA) fighter from the Western United States presented to liver clinic for elevated liver injury tests (LIT) and a 35-pound weight loss with associated diarrhea, lower extremity edema, dyspnea on exertion, and worsening fatigue over a period of 6 months. Past medical history includes concussion, right bundle branch block, migraine headache, hypertension, chronic pain related to musculoskeletal injuries and fractures secondary to MMA competition. Involvement in MMA was extensive with an 8-year history of professional MMA competition and 13-year history of MMA fighting with recurrent trauma to the chest wall. The patient also reported a 20-year history of performance enhancing drugs including testosterone. Physical exam was notable for elevated jugular venous pressure, hepatomegaly, and trace peripheral edema. An extensive workup was performed including laboratory studies, abdominal computerized tomography, liver biopsy, echocardiogram, and cardiac magnetic resonance imaging. Finally, right and left heart catheterization—the gold standard—confirmed discordance of the right ventricle-left ventricle, consistent with constrictive physiology. Pericardiectomy was performed with histologic evidence of chronic pericarditis. The patient’s hospital course was uncomplicated and he returned to NYHA functional class I. Conclusions CP can be a sequela of recurrent pericarditis or hemorrhagic effusions and may have a delayed presentation. In cases of recurrent trauma, CP may be managed with pericardiectomy with apparent good outcome. Further studies are warranted to analyze the occurrence of CP in MMA so as to better define the risk in such adults.

Hospital Mortality and Length of Stay for Patients with Myelodysplastic Syndrome Presenting with Acute ST-Elevation Myocardial Infarction (STEMI)

Introduction Ischemic heart disease remains the single largest cause of death worldwide. In the USA, 365,744 deaths were associated to coronary heart disease, and the mortality is highest in population older than 65 years old. Myelodysplastic syndromes (MDS) also mainly affect this group age and studies suggest an incidence as high as 75 cases per 100,000 aged >65 years. In the following abstract we analyze the mortality rate in patients with MDS and STEMI. Methods We conducted a retrospective analysis of 3 years of National inpatient sample (HCUP-NIS) data base from 2016 to 2018. Patients older than 60 years old and with or without MDS were selected using ICD-10 diagnosis code. Principal diagnosis of STEMI was included with the code. ICD-10 procedure code was used for left heart catheterization. Discharge-level weight analysis was used to produce a national estimate. Continuous variables were compared by t-test, while chi-square and Fisher's exact test were used for categorical variables. Finally, multivariate logistic regression was used to calculate odds ratio for inpatient mortality and multivariate linear regression for length of stay using STATA 17 statistical software. Results A total of 45,724,104 admissions met inclusion criteria, of those, 210,780 patients (0.46 %) have MDS. Patients with MDS are more likely to be of older age (78.7 v 74.8, p <0.00001), male (56.4% v 46.7%, p < 0.0001) and white (81.0% v 76.0%, p < 0.0001). They are also associated with lower prevalence of diabetes (16.2% v 20.1%, p < 0.003) and smoking (0.4% v 0.8%, p <0.0001) but higher prevalence of peripheral arterial diseases (12.7% v 11.6%, p <0.0001). During the study period, a total of 1,293,994 patients were admitted primarily due to STEMI, 3,270 of these patients (2.5%) had underlying MDS. Out of the 3,270, only 1,105 (33.8 %) underwent left heart catheterization. On the other hand, 735,610 patients without MDS (57.0%) underwent percutaneous coronary intervention. After adjusting for age, sex, race, diabetes, and Charlson comorbidity index, there was a statistical significant in mortality (OR 1.46, CI 1.08 - 1.98, p < 0.013) and longer length of stay by 0.59 day (p < 0.0001). Discussion In our study, MDS is associated with higher mortality and loner length of stay. Peripheral arterial diseases are found to be more prevalent in MDS even though other cardiovascular risk factors such as diabetes mellitus and smoking are less prevalent. It is consistent with prior study, by Jaiswal S et al, hypothesizing that MDS is an independence risk of atherosclerotic cardiovascular diseases. Interestingly, patients with MDS are less likely to undergo left heart catheterization which is the definitive intervention for diagnosis and treatment of ischemic heart diseases. We recommend our hematology society to identify and treat the cardiovascular risk factors in these patients. Further studies will be required to develop a standardized evaluation and management plans for MDS population. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Old Is (Not) Gold: Midazolam Monotherapy versus Midazolam Plus Fentanyl for Sedation during Cardiac Catheterization

Objective. We aimed to study the differences in perception of pain during cardiac catheterization with midazolam monotherapy compared to the current standard of midazolam plus fentanyl. Background. Procedural sedation is important to ensure comfort and safety in patients undergoing left heart catheterization. Despite the widespread use of midazolam and fentanyl for procedural sedation, the effectiveness of this dual agent approach to sedation has never been studied in comparison to midazolam monotherapy. Methods. A total of 129 patients undergoing sedation for outpatient elective cardiac catheterization were randomly assigned to either midazolam monotherapy (n = 69) or combination of midazolam and fentanyl (n = 60). The primary outcome was assessment of pain perception prior to discharge by patient completion of a pain questionnaire. Participants were asked if they experienced any pain during their procedure (yes/no) and, if yes, asked to rate their overall pain level using a 10-point Likert scale that ranged from 1 (minimal pain) to 10 (worst pain imaginable). Results. Most patients (n = 94, 73%) reported no pain during their procedure. Patients sedated with midazolam monotherapy reported similar average pain scores compared to patients sedated with the combination of midazolam and fentanyl (1.1 vs. 1.1, p = 0.95 ). Conclusions. Among patients undergoing elective cardiac catheterization, no significant differences in pain scores were noted between sedation with midazolam alone compared to midazolam and fentanyl. Due to fentanyl’s unfavorable interaction with P2Y12 agents, increased costs, and addiction potential, it is imperative that cardiologists revisit the role of effective procedural sedation with a single agent and avoid the use of fentanyl.

Association of Kidney-Related Safety Events with Incident Chronic Kidney Disease in Veterans

Objective: The impact of Nonsteroidal Anti-Inflammatory Drugs (NSAID) and iodine-based contrast exposures on developing Chronic Kidney Disease (CKD) is controversial. We examined the association of these exposures with the development of CKD in a Veteran population. Methods: A retrospective case-control study of 154,448 veterans from the Veterans Affairs (VA) Corporate Data Warehouse (CDW) database between 2005 and 2014 was conducted to assess the association between incident stage 3 CKD with Acute Kidney Injury (AKI), NSAID use, iodine-based contrast exposures, and comorbid conditions. Stepwise logistic regression was used to determine multivariable adjusted Odds Ratios (OR). Results: The mean age was 59 (SD±13), and the median eGFR was 84 (IQR: 73, 96). AKI was associated with increased odds of CKD (inpatient: OR=3.76, 95% CI: 3.44, 4.11; outpatient: OR=4.73, 95% CI: 4.09, 5.46) and demonstrated escalated odds with >1 episode (inpatient: OR=5.72, 95% CI: 4.71, 6.95; outpatient: OR=8.36, 95% CI: 6.32, 11.06). Months of NSAID prescriptions was associated with CKD, with ORs at >0-6 months, >6-12 months, and >12 months of 1.27 (95% CI: 1.23, 1.32), 1.54 (95% CI: 1.46, 1.63), and 1.69 (95% CI: 1.62, 1.77) respectively. Iodine-based contrast exposure was associated with increased odds of CKD, with ORs for 1-2 Computed Tomography (CT) scans, ≥3CT scans, and left heart catheterization of 1.29 (95% CI: 1.24, 1.35), 1.29 (95% CI: 1.20, 1.28), and 1.38 (95% CI: 1.17, 1.63) respectively. Conclusion: AKI events, NSAID use, and iodine-based contrast exposures are associated with increased odds for developing stage 3 CKD in veterans.

LA reservoir Strain: A Sensitive Parameter for Estimating LV Filling Pressure in Patients with Preserved EF

Aims: An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction, which is estimated with an algorithm by the recent ASE/EACVI guideline. In this study, we sought to determine the efficacy of the LA global longitudinal strain to estimate the elevated LV filling pressure. Methods and Results: Consecutive patients who underwent left ventricular catheterization between January 2016 and December 2018 were included. Transthoracic echocardiography was performed within 24hrs before the catheterization. The LV filling pressure was estimated using echo parameters based on the 2016 ASE/EACVI algorithm. Moreover, to evaluate left atrial function, the LA GLS was measured using 2D speckle tracking echocardiography on four chamber-view (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to mean left atrial pressure (LAP) was used as a reference, and >12 mm Hg was defined as elevated.71 patients (mean age of 63.2±9.75, 70.4% male) underwent left heart catheterization. Invasive LV filling pressure was defined as elevated in 41 (57.8%) and normal in 30 patients (42.2%). 9(12.7%) patients of 71 were defined as indeterminate based on the 2016 algorithm. Using the ROC method, the accuracy of the algorithm was found as AUC:0.75 with 77% specificity and 70% sensitivity. The accuracy of 25.5 % cut point of LASr was found as AUC:0.79 with 77% specificity and 80% sensitivity for estimating LAP.Conclusions: LASr with higher sensitivity may add an incremental value to estimate LV filling pressure, and hence may be used for HFpEF diagnosis.

Interventional cardiology for coronary heart disease

The purpose of this chapter is to give an overview of interventional cardiology. Diagnostic angiography and percutaneous coronary intervention (PCI) are discussed, in addition to related issues (e.g. achieving haemostasis, pharmacological adjuncts, and complications). The principles of nursing care for both angiography and PCI are similar and will, ∴, be discussed together; any differences will be clarified. Although coronary angiography is the focus of this chapter, it is worth noting that cardiac catheterization is the passage of a catheter into the left and/or right heart to provide diagnostic information about the heart and blood vessels. Cardiac catheterization is a generic term that refers to a variety of procedures including angiography, ventriculography, and right or left heart catheterization. ∴ abnormalities of the heart valves, heart muscle, and coronary arteries can be identified by these procedures.

Abstract 337: Trends and Outcomes with Early Left Heart Catheterization in Post-Out-of-hospital Cardiac Arrest

Background: Left heart catheterization (LHC) and TTM are proven beneficial after OHCA. Detroit CARES data found a strong, though insignificant, trend for LHC rate and survival (p = 0.1). In 2018, the rate of patients with LHC and good CPC nearly doubled, despite an overall decrease in LHC rate. Therefore, we hypothesize LHC is performed later (after second day of hospitalization) nationwide and a good CPC is likely associated with selection of patients expected to survive. Methods: We analyzed the national CARES registry (2013 - 2018) to investigate whether delayed LHC after OHCA was occurring nationally. Included were patients 18 or older, non-skilled care facility patients and surviving to admission. The primary outcome was the CPC dichotomized into good (1 or 2) and poor (3 - 5). A propensity score was derived to predict early LHC that incorporated factors associated with LHC and outcome. A multi-level logistic regression analyses was fit using inverse weighted propensity scores. The primary predictor of interest was early LHC relative to no or late LHC. Also examined were TTM, year of cardiac arrest, and other predictors. Results reported are odds ratios (OR) and the corresponding 95% confidence intervals (95% CI). Results: 62,195 individual cases were identified; the median age was 61, (IQR-16), 62% male, 32% unwitnessed, 37% bystander CPR, and 35% initial shockable rhythm. 29% had good outcome and 22% received early LHC, 6% late LHC and 72% no LHC. 13% of patients receiving early LHC and 23% with no or late LHC had a good outcome. OR and 95% CI for good outcome were: 2.4 (2.2-2.7) for early LHC, 3.6 (3.3-3.8) for shockable rhythm, 1.9 (1.7-2.0) for public location and 2.0 (1.8-2.2) for witnessed arrest. Over the five-year period, no change in the total LHC occurred and a slight decrease in early LHC, (25%-23%), (Fig 1). Conclusion: Early LHC was associated with good outcome (CPC) at hospital discharge. The overall LHC rate is unchanged from 2013-18 with a slight decrease in early LHC.

Abstract 14808: Acute Kidney Injury and Adverse Outcomes in Patients Undergoing Right Heart Catheterization versus Patients Undergoing Right and Left Heart Catheterization and Coronary Angiography

Background: Contrast induced nephropathy (CIN), or contrast-induced acute kidney injury is considered a complication of intravascular administration of iodinated contrast material. However, more recent studies have challenged the reported incidence of contrast nephropathy. We compared the incidence of acute kidney injury and of nephropathy at 3 months in patients undergoing only right heart catheterization (RHC) to patients undergoing right and left heart catheterization (R&LHC) and coronary angiography. Methods and Results: We studied 1779 consecutive patients at a Veterans Administration Medical Center, of which 869 underwent only RHC, which does not involve the administration of iodinated contrast media, and 910 patients who underwent R&LHC and coronary angiography. Creatinine values at 72 hours after the respective procedure were available in 938 patients and creatinine values at 3 months were available in 1246 patients. The incidence of acute kidney injury (defined as an increase in serum creatinine of 0.5 mg/dL or 25% compared to baseline) at 3 days was 34 (7.5%) in the RHC group and 46 (9.5%) in the R&LHC group (P=0.31). The incidence of nephropathy at 3 months was 89 (15.6%) in the RHC group and 113 (12.2%) in the R&LHC group (P=0.15). On multivariable analysis including adjustment for a propensity score, CIN at 3 days was not significantly associated with R&LHC (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.98-1.05; P=0.56) and neither was nephropathy at 3 months (OR 1.01, 95% CI 0.98-1.04; P=0.22). Patients undergoing R&LHC had a lower mortality at 12 months (hazard ratio 0.57, 95% CI 0.43-0.77; P<0.001). Conclusions: The incidence of acute kidney injury was not significantly different in patients undergoing RHC compared to patients undergoing R&LHC and coronary angiography, even though the former received no contrast dye. The incidence of nephropathy at 3 months was also not significantly different between the two groups while mortality was significantly lower in the group of patients undergoing R&LHC. This suggests that serum creatinine is a nonspecific diagnostic marker for contrast induced-kidney injury and that long-term outcomes are not associated with the administration of contrast in this population.