8613 Background: Little guidance is available regarding the optimum placement and use of implantable venous access devices (VAD) in cancer treatment. We present herein 10 years of experience with VAD in a university hospital oncology clinic. Methods: Post hoc analysis of prospectively collected records of 346 cancer patients in whom 362 VAD (Port-a-Caths) were placed between January 1995 to December 2005. Primary end points included need for instillation of tissue plasminogen activator (TPA) to restore patency, need for an x-ray dye study to determine catheter salvageability, and premature removal because of VAD failure. We used Chi-square analysis to compare VAD placement by the Radiology service under fluoroscopy vs. placement by Surgery in the operating room (OR), placement in the right vs. left chest and internal jugular (IJ) vs. subclavian (SC) vein placement. Results: OR-placed VAD, more often than Radiology-placed VAD required TPA for patency (18.6% vs 8.07%, p<0.01), a dye study (11.7% vs 2.69%, p=0.001) or premature removal (14.7% vs 5.38%, p<0.01). Right- and left-sided VAD were equally likely to receive TPA (9.2% vs 16.1%, p=0.11) but left-sided VAD required more dye studies (3.3% vs 10.7%, p=0.013) and were prematurely removed more often (5.5% vs 15%, p=0.007). 29 (8%) of VAD were prematurely removed because of infection (n=11), thrombosis(n=6), pain (n=2), mechanical malfunction (n=6) and others (n=4). Gender, age (< vs. > 60 years), site of placement (IJ vs. SC) or body mass index (< vs. > 25) had no bearing on the primary endpoints. Intrathoracic cancer was associated with more TPA treatment of the VAD (16.8% vs. 8.4%, p<0.023) but not with dye studies (7.9% vs. 4%, p=0.191) or removal (6.1% vs. 8.8%, p=0.517). Conclusions: AVAD will usually last until completion of cancer therapy. Occlusion or premature removal is less likely in a VAD placed on the right side under fluoroscopic guidance by an experienced radiologist. Thoracic disease, site of placement, obesity, age or gender do not determine adverse outcomes for VAD. No significant financial relationships to disclose.
Abstract Background Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure.(1) Right ventricular failure (RVF) is a cause of major morbidity and mortality after LVAD implantation.(2,3) Our objective was to get the outcomes and predictors of RVF in adult patients undergoing LVAD implantation. Methods This retrospective study enrolled 73 adult patients with LVAD (Heart Mate III) implantation, of them 24(32.9%) patients had RVF after LVAD implantation. Results The patients with RVF had statistically significant more frequencies of acute kidney injyry (p<0.001), new need for dialysis(p<0.001), RVAD insertion (p<0.001), total mortality (p=0.012) and on-VAD mortality(p=0.018) with prolonged ICU stay (p<0.001) compared to the non-RVF group respectively. The pre-LVAD pulmonary vascular resistance(PVR) ≥3 WU (OR:2.4, 95%CI: 1.52-7.38, p=0.04) and diastolic pulmonary gradient(DPG) ≥ 7 mmHg (OR:6.4,95%CI: 5.49-18.6, p<0.001) were the independent predictors of RVF after LVAD implantation. Cox proportional regression analysis revealed that RVF was associated with increased risk of death (HR:3.12,95%CI:1.42-6.85, p=0.005). Conclusion Early RVF post-LVAD carries significant risks of mortality and multiple morbidities. Concomitant BiVAD implantation needs to be considered in patients with elevated DPG and PVR to avoid post-LVAD RVF.The significant variables of patients.Kaplan-Meier curves of the 2 groups.
Elective percutaneous coronary intervention (PCI) is associated with myocardial necrosis, as evidenced by troponin release, in approximately one-third of cases. This is known to be linked with subsequent cardiovascular events. This study assessed the ability of remote ischemic preconditioning (RIPC) to attenuate cardiac troponin T (cTnT) release after elective PCI.Evaluation of effect of RIPC on myocardial markers following elective PCI.One hundred and forty nine consecutive patients undergoing elective PCI with undetectable preprocedural cTnT were recruited. Subjects were randomized to receive RIPC (induced by three 5-min inflations of a blood pressure cuff to 200 mm Hg around the upper arm, followed by 5-min intervals of reperfusion) or control (cuff deflated) immediately before arrival in the cardiac catheterization room. The primary outcome was cTnT level at approximately 16 hr after PCI. Secondary outcomes included occurrence of postprocedural myocardial infarction (MI), CKMB levels at 16 hr after PCI and assessment of the inflammatory response as measured by C-reactive protein (CRP) levels.The mean cTnT at 16 hr after PCI was lower in the RIPC group compared with the control group. (0.020 vs. 0.047 ng/ml; P = 0.047) Occurrence of postprocedural MI, CKMB and CRP levels did not differ in both groups (P = 0.097, 0.537, and 0.481 respectively).The use of RIPC immediately prior to PCI attenuates procedure-related cTnT release and does not affect occurrence of post procedural MI, CKMB, or CRP levels.
Coronary artery vasospasm, or Prinzmetal angina, remains a challenging diagnosis. Prinzmetal angina usually affects only one coronary vessel; however, in this case, it occurred simultaneously in three coronary arteries, and was totally relieved after nitrate administration.
The left ventricular assist devices (LVADs) are increasingly used for advanced heart failure as a bridge to heart transplantation or as a destination therapy. The aim of this study was to investigate the changes of diastolic pulmonary gradient (DPG), pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) after LVAD implantation and their impact on survival after LVAD and heart transplantation.A total of 73 patients who underwent LVAD (HeartMate III) implantation between 2016 and 2022 were retrospectively studied. According to pre-LVAD catheterization, 49 (67.1%) patients had DPG < 7 mmHg and 24 (32.9%) patients had DPG ≥ 7 mmHg. The patients with a pre-VAD DPG ≥ 7 mmHg had higher frequencies of right ventricular (RV) failure (p < 0.001), RVAD insertion (p < 0.001), need for renal replacement therapy (p = 0.002), total mortality (p = 0.036) and on-VAD mortality (p = 0.04) with a longer ICU stay (p = 0.001) compared to the patients with DPG < 7 mmHg. During the follow-up period of 38 (12-60) months, 24 (32.9%) patients died. Pre-LVAD DPG ≥ 7 mmHg (adjusted HR 1.83, 95% CI 1.21-6.341, p = 0.039) and post-LVAD DPG ≥ 7 mmHg (adjusted HR 3.824, 95% CI 1.482-14.648, p = 0.002) were associated with increased risks of mortality. Neither pre-LVAD TPG ≥ 12 (p = 0.505) nor post-LVAD TPG ≥ 12 mmHg (p = 0.122) was associated with an increased risk of death. Pre-LVAD PVR ≥ 3 WU had a statistically insignificant risk of mortality (HR 2.35, 95% CI 0.803-6.848, p = 0.119) while post-LVAD PVR ≥ 3 WU had an increased risk of death (adjusted HR 2.37, 95% CI 1.241-7.254, p = 0.038). For post-transplantation mortality, post-LVAD DPG ≥ 7 mmHg (p = 0.55), post-LVAD TPG ≥ 12 mmHg (p = 0.85) and PVR ≥ 3 WU (p = 0.54) did not have statistically increased risks. The logistic multivariable regression showed that post-LVAD PVR ≥ 3 WU (p = 0.013), post-LVAD DPG ≥ 7 mmHg (p = 0.026) and RVF (p = 0.018) were the predictors of mortality after LVAD implantation. Pre-LVAD DPG ≥ 7 mmHg (p < 0.001) and pre-LVAD PVR ≥ 3 WU (p = 0.036) were the predictors of RVF after LVAD implantation.Persistently high DPG was associated with right ventricular failure and mortality after LVAD implantation rather than after heart transplantation. DPG is a better predictor of pulmonary vascular remodeling compared to TPG and PVR. Further larger prospective studies are required in this field due to the growing numbers of patients with advanced heart failure, as possible candidates for LVAD implantation, and limitations of heart transplantation.
Woven coronary artery anomaly is a rare description of an epicardial vessel segment that divides into multiple intertwining segments with eventual convergence of the distal vessel. We present our case, a 57-year-old male with an incidental woven coronary artery anomaly found during work-up investigations for a possible lung transplant, and we conduct a literature review on woven anomaly cases reported from 1988 to 2021 and provide a thorough analysis of its diversified clinical presentation. Imaging identification and various treatment modalities are also discussed.
Background and aims: Two types of NRS are commonly used in pediatric population:non-invasive continuous positive airway pressure (nCPAP) and non-invasive pressure support ventilation (PS-NIV),they have been used for similar indications. Aims: Aim of this study to compare the use of n-CPAP with PS-NIV in a pediatric intensive care unit at tertiary hospital to understanding the effectiveness of NRS therapy in a particular proportion of children require escalation therapy, and how to recognize those who require more advanced respiratory support by using bed side monitor data together with arterial blood gas (respiratory score and hypoxic score). Methods: This was retrospective observation study at period January 2012 till June 2013 at PICU Elkhadra Hospital Tripoli-Libya; data were collected on all children who were managed at PICU from PICU data record. The patients who were not improved after 2hrs,4hrs from study required invasive respiratory support and mechanical ventilation. Results: As the first mode NRS, 27 children received nCPA, and 28 received PS-NIV.For patients (14.8%) received nCPAP required intubation and mechanical ventilation compared with children with PS-NIV (14.2%)required intubation and MV. The need to escalation to mechanical ventilator at 2 hrs,4 hrs from the starting of NRS could be predicted by failure of normalization of respiratory score and hypoxic score. PS-NIV group has lower hypoxic score than nCPAP group p<0.001 and older p<0.004 respectively. Conclusions: PS-NIV is effective NRS for older children with sever respiratory distress.
We report the incidence, patient characteristic with clinical outcomes in patients with homozygous familial hypercholesterolemia (HoFH) in Saudi Arabia. This is a retrospective and prospective, single center study which included 37 patients 14 years and older enrolled and followed up between 2018-2021 for three years. 46% were females, 78% were offspring of consanguineous marriage. LDLR mutation was in 78% and LDL-C/LDLRAP in 3% of patients. Mean LDL-C at the first presentation was 14.2±3.7 mmol/L, average Dutch lipid score was 20.9±6.24. LDL apheresis was performed on 70% of patients. Most patients were on ezetimibe (92%), high-dose statins ( 84%) and PCSK9 inhibitors (32%). 48.6% had aortic stenosis, out of which 30% had severe aortic stenosis. Ten underwent aortic valve surgery (5 mechanical valve, 3 Ross procedure, 1 aortic valve repair, 1 bioprosthetic valve) and one had transcatheter aortic valve implantation (TAVI). Coronary artery bypass surgery (CABG) was performed on 32% and percutaneous intervention (PCI) on 11% of patients. HoFH patients have complex diseases with high morbidity and mortality, and benefit from a highly specialized multidisciplinary clinic to address their clinical needs. Although there are several therapeutic agents on the horizon, early diagnosis, and treatment of HoFH remain critical to optimize patient outcomes.
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