Cardiology Commons^™

Code Status In The Inpatient Setting, Alyssa Harper, Travis Fisher, Marjorie Schoen, Caroline Pappas, Ian May

View All Graduate Medical Education Content

No abstract provided.

Qi Project: Clopidogrel In Nstemi, Amanda Sams, Erin Kaya, Carsten Kirby, Ester Peters, Michael Stewart (Faculty Advisor)

Articles, Abstracts, and Reports

No abstract provided.

Complications Of Cardiopulmonary Bypass From An Anesthesia Perspective: A Clinical Review, Alex Roberts, Elizabeth C. Duncan, Paul Hargrave, David Redding Kingery, Josh Barnes, Derek L. Horstemeyer, Russell F. Stahl

HCA Healthcare Journal of Medicine

Cardiopulmonary bypass (CPB) is frequently used for open heart surgery and other procedures that utilize temporary substitution or support of heart and lung function. While it is widely accepted as the predominant method to carry out these procedures, it is not without possible complications. CPB can be seen as the ultimate “team sport” as it includes and is dependent on contributions from multiple professionals including anesthesiologists, cardiothoracic surgeons, and perfusion technicians. In this clinical review paper, we examine possible complications of CPB, primarily from the perspective of the anesthesiologist, and how to troubleshoot them if they arise, which often requires …

Journal Of Shock And Hemodynamics, Vol. I, Iss. 2 (Print Version)

Journal of Shock and Hemodynamics

The print version of Volume I, Issue 2 of the Journal of Shock and Hemodynamics was published in February 2023. The PDF of the print version is downloadable here.

Variance In Management Of Extracorporeal Membrane Oxygenation-Associated Fibrin Sheaths At A Single Institution, Alexandra Tedesco Md, Monica Majumdar Md, Jamel P. Ortoleva Md, Christine Nayar Md, Masashi Kawabori Md, Payam Salehi Md, Ali Irshad Md

Abington Jefferson Health Papers

Objective: Extracorporeal membrane oxygenation (ECMO) support for patients with cardiac or respiratory failure has been increasingly used by advanced critical care practitioners. The thromboembolic complications of ECMO have been extensively discussed and researched; however, research and discussion on the development, risks, and management of cannulae-associated fibrin sheaths are lacking.

Methods: Institutional review board approval was not required. We have presented three cases detailing the identifi- cation and individualized management of ECMO-associated fibrin sheaths at our institution. The three patients provided written informed consent for the report of their case details and imaging studies.

Results: Of our three patients with ECMO-associated …

Management Of Patients With Refractory Cardiogenic Shock And Cardiointestinal Syndrome With Impella 5.5 As Bridge To Decision: Case Series, Ismael A. Salas De Armas, Bindu Akkanti, Amanda Bergeron, Anju Bhardwaj, Kha Dinh, Ali Shirafkan, Jayeshkumar A. Patel, Manish K. Patel, Carlos R. Manrique Neira, Igor D. Gregoric, Biswajit Kar, Mehmet H. Akay

Journal of Shock and Hemodynamics

Patients with advanced heart failure require multi-system management as a majority succumb to end-organ dysfunction, including gastrointestinal sequelae. Temporizing measures, such as early mechanical circulatory support, can assist in the recovery of patients with acute cardiogenic shock. The temporary support can improve patient characteristics to enable future definitive heart failure therapies such as durable left ventricular assist devices and orthotopic heart transplantation. We present two cases of cardiogenic shock that were successfully bridged with an Impella 5.5 (Abiomed). The management enabled the patients to recover from reversible cardiointestinal syndrome and undergo successful definitive therapies.

Revascularization In Cardiogenic Shock: Residual Syntax Score And Chronic Total Occlusions, Venugopal Menon

Journal of Shock and Hemodynamics

The residual syntax score (rSS) is strongly associated with outcomes in patients with stable coronary artery disease. In patients with acute myocardial infarction-associated cardiogenic shock (AMI-CS), the correlation or association of the rSS, mortality risk, and revascularization strategy has not yet been elucidated and needs more investigation. The SHOCK trial demonstrated that patients with left main and severe triple-vessel disease, who underwent coronary artery bypass grafts, had improved outcomes and higher 1-year survival rates than those with initial medical stabilization. However, it is unclear which is the superior technique for achieving complete revascularization. In contrast to the SHOCK trial’s results, …

Covid-19 Induced Right Ventricular Failure And Right Ventricular Assist Device Support, Marvin Slepian M.D.

Journal of Shock and Hemodynamics

COVID-19, while primarily recognized for its pulmonary and systemic manifestations, afflicts the cardiovascular system through various abnormalities. Notably, right ventricular (RV) involvement leading to dysfunction and failure is a manifestation seen in up to 20% of severe COVID patients. RV severity correlates with overall COVID severity, serving as a prognostic marker. Data review reveals that RV failure was largely underdiagnosed, particularly early on in the pandemic. The therapy approach for RV failure in patients with COVID should focus on supporting overall RV perfusion pressure, maintaining sinus rhythm, optimizing RV loading conditions and contractility, and addressing anticoagulation and thrombus-related conditions. Beyond …

Right Ventricular Hemodynamics In Covid-19 Patients, Steven Hollenberg

Journal of Shock and Hemodynamics

The right ventricle is highly sensitive to afterload, and pulmonary compromise can increase pulmonary vascular resistance and lead to right ventricular dysfunction. Pulmonary hypertension can also be exacerbated by mechanical ventilation. Patients with COVID-19 pneumonia and respiratory failure, especially those ventilated with positive end-expiratory pressure, are prone to pulmonary hypertension. Understanding their right ventricular hemodynamics can have therapeutic and prognostic implications.

Coronary Flow And Unloading In Acute Myocardial Infarction Shock, Kiyo Ishikawa

Journal of Shock and Hemodynamics

In patients with cardiogenic shock that undergo successful coronary intervention, there are still factors complicating myocardial recovery. There is room for improvement in coronary flow using mechanical circulatory devices, specifically by left ventricular unloading. This idea was further explored in a research study using pigs. Results showed that subjects with acute myocardial infarction who have reduced cardiac contractility and/or high diastolic pressure would benefit from support strategies targeting left ventricular unloading.

Recurrent Cyanotic Spells In An Octogenarian, Chin Tong Kwok, Chun Kit Wong

Journal of the Hong Kong College of Cardiology

We report rare case of an octogenarian who, after years of diagnostic delay, was found to have a patent foramen ovale, and due to an ascending aortic aneurysm that anatomically facilitated right-to-left shunt, presenting with life-threatening cyanotic attacks. The characteristic orthodeoxia-platypnea syndrome and high alveolar arterial gradient hint to the diagnosis. She was eventually treated successfully with urgent percutaneous PFO closure. Routine ordering of a transthoracic echocardiogram, without agitated saline injection under provocation maneuvers, may not be sufficient to rule out shunts.

The Challenges Of Conducting Clinical Trials For Patients With Cardiogenic Shock, Sunil Rao

Journal of Shock and Hemodynamics

Cardiogenic shock due to ST-segment elevation myocardial infarction is associated with high morbidity and mortality. Patients in shock are acutely ill, and clinicians may lack equipoise, thus presenting a challenge to developing high-quality evidence to guide practice. This review will summarize these challenges and offer possible solutions.

Unfavorable Social Determinants Of Health Are Associated With Higher Burden Of Financial Toxicity Among Patients With Atherosclerotic Cardiovascular Disease In The Us: Findings From The National Health Interview Survey, Javier Valero-Elizondo, Zulqarnain Javed, Rohan Khera, Mauricio E. Tano, Ramzi Dudum, Isaac Acquah, Adnan A. Hyder, Julia Andrieni, Garima Sharma, Salim S. Virani

Office of the Provost

Background: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood.
Methods: Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 …

Why Is Epinephrine Not The Drug Of Choice In Cardiogenic Shock?, Esther Vorovich

Journal of Shock and Hemodynamics

Through the years, epinephrine has been the drug of choice for patients with cardiogenic shock. However, epinephrine was clinically inferior to norepinephrine in comparison studies because of the negative patient outcomes, which were statistically significant. These effects include type B lactic acidosis, tachycardia, increased myocardial oxygen demand, and arrhythmias.

Profound Vasoplegia After Coronary Artery Bypass Grafting, Subhasis Chatterjee

Journal of Shock and Hemodynamics

Vasoplegic shock after cardiac surgery is characterized by a high cardiac output, low systemic vascular resistance, refractory hypotension, and ongoing need for vasopressors. In this case, management considerations are discussed, including vasoactive medications and other adjuncts to sustain a satisfactory mean arterial pressure and improve outcomes.

Reperfusion Injury In Acute Myocardial Infarction Shock- Role Of Mechanical Circulatory Support Devices, Finn Gustafsson

Journal of Shock and Hemodynamics

The efficacy of mechanical circulatory support in acute myocardial infarction is dependent upon the size of the infarct. If applied early, mechanical support to reduce reperfusion injury appears to be effective in reducing infarct size in animal studies. The optimal timing of reperfusion is uncertain and requires further investigation. Efficient unloading appears to be essential in increasing the efficacy of the type of mechanical support and may favor one over another.

Racial Variations In Shock Presentation And Outcome, Steven Bailey

Journal of Shock and Hemodynamics

Working toward inclusive strategies for data sampling, trials, and triage is essential. Whatever the approach, it is important to do better than what has been done in the past when considering race and ethnicity in patient care. Although there may be limited publications with information on this topic, they have shown clear differences in patient outcomes with possible associations with gender, race, and ethnicity. It is critical to view the implications of this on socioeconomic status, access, resources, patient phenotypes, and patient desires and expectations. The disparities must first be recognized before any treatment options can be identified.

Hemodynamic Goals In Shock Management: Is There One Target For All?, Maya Guglin

Journal of Shock and Hemodynamics

The current guidelines for managing cardiogenic shock lack specificity and clarification. The main criterion for cardiogenic shock is low cardiac output, and the most important goal is to achieve adequate output from a shock state. Because of the complex nature of cardiogenic shock, a “one-size-fits-all" outline may not be the best solution. Historically, hemodynamic goals in cardiogenic shock are copied from septic shock. Because septic shock and cardiogenic shock are different hemodynamic entities, the goals should be different.

Hemodynamics And Kinetics Of Heart Failure With Preserved Ejection Fraction Shock, Yevgeniy Brailovsky, J. Eduardo Rame, Thierry Le Jemtel, Indranee Rajapreyar

Journal of Shock and Hemodynamics

The classical paradigm of cardiogenic shock is severe impairment of left ventricular, right ventricular, or biventricular contractility resulting in decreased cardiac output and end-organ failure. In patients with preserved ejection fraction, cardiogenic shock results from impaired left ventricular filling leading to decreased cardiac output and end-organ hypoperfusion. Heart failure with preserved ejection fraction (HFpEF) comprises a heterogenous group of myocardial and systemic metabolic derangements. Cardiogenic shock with preserved left ventricular ejection is thought to be less common than with reduced left ventricular ejection fraction, and therapeutic approaches are not well standardized. We aim to review the pathophysiology of cardiogenic shock …

Effectiveness Of Non-Invasive Respiratory Support Strategies In Patients With Covid-19: A Systematic Review And Meta Analysis, Vinesh Kumar, Umair Arshad Malik, Reshman Kumari, Berkha Berkha, Vijay Kumar, Manoj Kumar, Simran Simran, Suman Suman, Bushra Nasim

Medical College Documents

Background: The effectiveness of non-invasive respiratory strategies, namely CPAP and HFNO, in reducing the risk of mortality and tracheal intubation in patients with severe COVID-19 is not well established.
Methods: A thorough literature search was conducted across 3 electronic databases (Medline, EMBASE and Cochrane Central) from inception through July 2022. Randomized controlled trials (RCTs) and observational studies assessing the impact of CPAP or HFNO on clinical outcomes in patients infected with COVID-19 were considered for inclusion. End-points included all-cause mortality and risk of tracheal intubation. Evaluations were reported as risk ratios (RRs) with 95% confidence intervals (CI) and analysis was …

Sociodemographic Determinants Of Oral Anticoagulant Prescription In Patients With Atrial Fibrillations: Findings From The Pinnacle Registry Using Machine Learning, Zahra Azizi, Andrew T. Ward, Donghyun J. Lee, Sanchit S. Gad, Kanchan Bhasin, Robert J. Beetel, Tiago Ferreira, Sushant Shankar, John S. Rumsfeld, Salim S. Virani

Office of the Provost

Background: Current risk scores that are solely based on clinical factors have shown modest predictive ability for understanding of factors associated with gaps in real-world prescription of oral anticoagulation (OAC) in patients with atrial fibrillation (AF).
Objective: In this study, we sought to identify the role of social and geographic determinants, beyond clinical factors associated with variation in OAC prescriptions using a large national registry of ambulatory patients with AF.
Methods: Between January 2017 and June 2018, we identified patients with AF from the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) Registry. We examined associations between patient …

A Quantification And Impact Of Incomplete Revascularization Using Residual Syntax Score In Nstemi Patients After Percutaneous Coronary Intervention, Syed Waqar Ahmed, Nasir Rahman

Section of Cardiology

Objectives: The aim of this study was to assess the prognostic significance of rSS after PCI for NSTEMI in terms of all-cause mortality and MACE (Major adverse cardiac event) at 3 years of follow-up.
Methodology: A retrospective analysis of 115 consecutive NSTEMI patients who underwent PCI at the Aga Khan University Hospital Karachi between January 2016 and December 2016 was performed. 7 patients were excluded from the final analysis due to missing data (n=108). The SYNTAX scores before (baseline syntax=bSS) and after PCI (rSS) were calculated. Patients were stratified as CR if rSS =0, RICR if rSS >0 and ≤8 …

Scai Shock: Does The Stage Help With Management Decisions?, Jacob C. Jentzer, David A. Baran

Journal of Shock and Hemodynamics

No abstract for an Editorial.

Future Perspectives In Acute Myocarditis Complicated By Cardiogenic Shock, Giovanni A. Tavecchia, Iside Cartella, Enrico Ammirati

Journal of Shock and Hemodynamics

Acute myocarditis is an inflammatory disease of the myocardium with a highly variable clinical course. Fulminant myocarditis (FM) represents the most threatening scenario with hemodynamic compromise and cardiogenic shock at presentation. Despite medical advances and the availability of promising mechanical circulatory support (MCS), FM is burdened by a dismal prognosis. Early referral to tertiary hospitals with MCS facilities and prompt diagnosis with endomyocardial biopsy are critical steps toward optimal management. Moreover, beyond supportive care, the prevention of irreversible myocardial damage with immunomodulating therapies must be proven in clinical trials. In this editorial, we briefly describe current evidence and future perspectives …

Surviving Sepsis Campaign: Strategies To Implement In Cardiogenic Shock Management, James Burke Md

Journal of Shock and Hemodynamics

The Surviving Sepsis Guidelines can serve as a structure to help educate and create a set of recommendations on how to care for patients through this complicated pathway of shock. Designing a cardiogenic shock bundle could reduce the variability of care and possibly improve survival. Also, a more standard protocol would allow a review of the outcomes and a system to change practice nationally when new data or technology becomes available. This could create a continuous quality improvement cycle. Creating a “Surviving Cardiogenic Shock” system could help provide awareness for recognition of cardiogenic shock and advanced management alternatives needed at …

Role Of Invasive Hemodynamics In Shock Management: Is A Pulmonary Artery Catheter Always Necessary?, Ajay J. Kirtane

Journal of Shock and Hemodynamics

The pulmonary artery (PA) catheter can be a useful tool in the management of patients with cardiogenic shock; however, there are challenges with the use of this catheter, and clinicians must balance the risks and benefits. In addition, clinicians must properly interpret data generated from a PA catheter in the context of other data to optimize a patient's hemodynamics.

Factors Influencing The Use Of Postoperative Bilevel Positive Airway Pressure (Bipap) In Patients Undergoing Adult Cardiac Surgery: A Retrospective Cohort Study, Syed Shabbir Ahmed, Muhammad Saad Yousuf, Khalid Samad, Hameed Ullah, Khalid Maudood Siddiqui

Department of Anaesthesia

Background and aims: Respiratory complications are one of the biggest challenges following cardiac surgery, which can lead to hypoxia and acute respiratory failure (ARF). The aim of this study to identify the factors led to BiPAP application for postoperative respiratory complications and its effectiveness as the main outcome measures after cardiac surgery.
Methods: It was a retrospective cohort study with consecutive sampling technique. A total of 335 postcardiac surgery patients medical record was reviewed who were underwent for surgery from November 1, 2018 to November 30, 2019. 265 patients were finalized for the recruitment, five patients were excluded before the …

Trends, Predictors, And Outcomes Of Transcatheter Aortic Valve Implantation In Patients With Bicuspid Aortic Valve Related Disease: Insights From The Nationwide Inpatient Sample And Nationwide Readmission Database, Waqas Ullah, Salman Zahid, Hamza Muhammadzai, Fouad Khalil, Arnav Kumar, Abdul Mannan Khan Minhas, Muhammad Zia Khan, Salim S. Virani, David L. Fischman, Pinak Shah

Office of the Provost

Background: Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with bicuspid aortic valve (BAV) related aortic stenosis (AS) with insufficient large-scale data on its safety.
Methods: The Nationwide Inpatient Sample and Nationwide Readmission Database (2011-2018) were queried to identify patients undergoing TAVI for BAV versus trileaflet aortic valve (TAV) associated AS. The in-hospital, 30- and 180-day odds of outcomes were assessed using a propensity-matched analysis (PSM) to calculate adjusted odds ratios (aOR) with its 95% confidence interval (CI).
Results: A total of 216,723 TAVI (TAV: 214,050 and BAV: 2,673) crude and 5,347 matched population (TAV: 2,674 and …

Hemodynamic Variations In Cardiogenic Shock Phenotypes, Jason Katz

Journal of Shock and Hemodynamics

Patients with cardiogenic shock are not all the same. They present with a variety of hemodynamic profiles and other features that may allow us to create specific phenotypes. It is possible that phenotyping these patients at presentation may then help us to identify the optimal and earliest therapies that will improve outcomes and, at the same time, help us to overcome some of the heterogeneity currently undermining clinical trials.

Pulmonary Hypertension With “Normal” Pulmonary Vascular Resistance, Marwan F. Jumean, Sriram Nathan, Maria Patarroyo Aponte

Journal of Shock and Hemodynamics

Abstracts not available for Perspectives.