ABSTRACT
Systemic immunoglobulin light-chain (AL) amyloidosis is a plasma cell disorder that can cause cardiomyopathy due to the extracellular deposition of amyloid in the heart. When left untreated, median survival is 6 months. We report a case of AL amyloidosis diagnosed on pathology of the explanted heart after transplantation in a patient who presented in cardiogenic shock. A 54-year-old woman with a recent diagnosis of nonischemic cardiomyopathy attributed to COVID-19 vaccine-associated myocarditis presented to a community hospital in cardiogenic shock. Right heart catheterization revealed elevated filling pressures (right atrium 19 mmHg, pulmonary capillary wedge 43 mmHg) and reduced cardiac index (2.1 L/min/m2). Echocardiography showed normal left ventricular size and wall thickness with severely reduced systolic function (ejection fraction 20%), findings that were unchanged from a study performed 3 months prior. The patient was started on inotropic support with milrinone and dobutamine and transferred to our institution. Shortly after transfer, she became unstable and we instituted mechanical circulatory support with venoarterial extracorporeal membrane oxygenation. Expedited heart transplant evaluation was completed and she was listed at status 1 priority. She was discharged on post-operative day 10 after uncomplicated heart transplantation. Pathology of the explanted heart revealed kappa AL amyloidosis. The patient was referred to oncology and began daratumumab monotherapy 3 months post-transplant with improvement in the light chain burden. Surveillance endomyocardial biopsies have not shown evidence of amyloidosis and the patient is doing well clinically. Early diagnosis and treatment of AL amyloidosis are vital to prevent progression of cardiomyopathy and may obviate the need for heart transplantation. For those who undergo heart transplantation, continued treatment directed at the plasma cell clone with chemotherapy or stem cell transplantation is essential to ensuring long-term success of the allograft. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Introduction: The coronavirus disease 2019 (COVID-19) pandemic has created challenges in the delivery of acute cardiovascular care. Here, we evaluate the clinical characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the COVID-19 pandemic. Hypothesis: COVID-19 time period will associate with longer door to intervention times, and increased all-cause mortality among patients presenting with AMICS. Methods: Using the National Cardiogenic Shock Initiative database, we identified 406 patients who presented with AMICS. This group was divided into those who presented prior to COVID-19 (N=346, 5/9/2016-2/29/20) and those who presented during the pandemic (N=60, 3/1/20- 11/10/20). Clinical characteristics, treatment patterns, and outcomes were compared between the two groups. Results: The median age (25 -75 percentile) of the cohort was 64 (55-72) years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be of Black race, and more likely to be of Hispanic and White race than patients presenting prior to COVID-19. Median door to balloon (89.5 vs. 88 mins, p=0.38), door to support (88 vs. 78 mins, p=0.13), and onset of shock to support (73.5 vs. 62 mins, p=0.15) times were not significantly different when comparing those who presented prior to with those who presented during the pandemic. Rates of transfer from another hospital, and cardiac arrest prior to arrival in the cardiac catheterization lab were similar between the two groups. ST-Elevation Myocardial Infarction presentations were increased during the COVID-19 period (95% vs 80%, p=0.01). In adjusted logistic regression models, time period (during vs pre-COVID-19) did not significantly associate with survival to discharge (OR 1.17, 95% CI 0.59-2.35, p=0.65) or with one month survival (OR 0.82, 95% CI 0.42-1.61, p=0.56). Conclusions: Care of patients presenting with AMICS has remained robust among hospitals participating in the National Cardiogenic Shock Initiative during the COVID-19 pandemic. th th .
ABSTRACT
Background: The COVID-19 pandemic has introduced numerous changes to clinical and administrative practices in heart transplantation. One change is the transition of transplant selection committee meetings from in-person to remote video conference in order to maintain social distancing requirements. The impact of this transition on committee members and patient care is unknown. Methods: A 35-item anonymous survey, adapted from the validated Telehealth Usability Questionnaire, was developed and distributed electronically to the UCLA heart transplant selection committee. Quantitative and qualitative descriptive analyses were performed. Results: Of 83 committee members queried, 46 (55%) responded. 50% were non-physician members and 50% were physician members, including 48% cardiologists, 13% anesthesiologists, and 9% surgeons. Over a 6 week period, there was a 5% increase in the average number of attendees from in-person to video meetings. Respondents were satisfied with the ease of use, interface quality, and interaction quality of the video conference system, except for the ability to see meeting attendees. Overall, respondents were satisfied with video meetings, agreeing that they could contribute effectively and achieve their goals over video. However, if given the choice, 54% still preferred the in-person format. Respondents did not feel that video meetings impacted patient care, such as ability to clarify clinical questions, create management plans, and determine and/or update transplant listing status. Multitasking, technology integration, and location convenience were the predominant positive aspects of video meetings, while communication was the main negative, including inability to see attendees, audio interruptions and barriers to communication flow. Communication and clinical decision-making were the predominant positive aspects of in-person meetings (Figure). Conclusions: The transition from in-person to remote video conference heart transplantation selection committee meetings during the COVID-19 era has been well-received and does not appear to affect committee members’ perception of their ability to deliver patient care. Future, longer-term studies are needed to evaluate the impact of video meetings on transplant-related outcomes.
ABSTRACT
Background: COVID-19 has drastically altered the delivery of medical care in the United States and beyond. Healthcare providers have been forced to rapidly innovate to mitigate the spread of infection and maintain social distancing. Telemedicine allows for the continuation of vital patient care while decreasing the risk of virus transmission. Objective: We conducted a survey to assess the satisfaction of both patients and providers with rapid implementation of an electronic medical record (EMR) based video visit system. Methods: A survey hyperlink was distributed through EMR messages to patients and emails to providers. Results: 74/376 patients (19.7%) and 8/10 (80%) providers completed the survey. The population consisted of advanced heart failure (n = 37, 50%), mechanical circulatory support (n = 4, 5.4%), transplant (n = 19, 25.7%) and general cardiology (n = 14, 18.9%) patients and their respective providers. The patient survey consisted of validated survey questions to assess patient and provider perceptions. Patients were 69.7% male with a mean age of 65. 74% of the patients consider themselves early adopters or innovators with new technology. 85% of surveyed patients believed that telemedicine is simple to use and easy to learn. 77% felt the telemedicine system interface was of good quality, 88% believed it allows for good interaction with the provider, 95% believed it protects both patients and providers by limiting exposure to COVID-19, 83% were overall satisfied with this telemedicine system and would use it again. 75% of providers reported no telemedicine experience prior to COVID-19. Notably, 100% of physicians consider themselves early adopters or innovators with new technology. 87.5% deemed their patients highly complex. 100 % of providers felt that telemedicine is useful for their job and 87.5% felt that their job would be difficult to perform without it, 27.5% believed video visits save and reduce time spent on unproductive activities, and allow accomplishing more work and tasks more quickly, 87.5% believe the system is easy to use overall, 100% agree it enhances providers’ and patients’ safety during COVID-19. Conclusion: Patients reported high level of satisfaction with video visits and interaction with their providers as well as with the ease of use and convenience of telemedicine appointments. Providers found the telemedicine system easy to use and useful for their job, but many believe there is room for improvement with respect to time saving measures.