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Introduction: Primitive data suggest prevalence of PH in patients with COVID19 is around 13% but prognosis is unclear. Approximately 0.5-2% of patients develop CTEPH after acute PE and recommendation is to screen them for CTEPH if remains symptomatic at 3/12 after PE. Aim(s): The primary aim of the study was to assess the chances of persistent PH following PE secondary to COVID19 Methods: We conducted a retrospective cohort study at a DGH in the UK. All patients diagnosed with COVID-19 and PE between April, 2020 to October, 2021 were examined. Patients were divided into two groups: . COVID19 and PE with co-morbidities(excluding pre existing PH) . COVID19 and PE without co-morbidities We compared the prevalence of pulmonary hypertension between the two groups on cardiac ECHO (defined as a mean pulmonary arterial pressure >= 25mmHg) at the time of diagnosis of PE and at 3 months following treatment. Result(s): 80 patients were included in the study (49 with co-morbidities & 31 with no co-morbidities). Average age of co-morbidities and no comorbidities groups were 73yrs and 70yrs respectively. Average PaO2/FiO2 ratio for comorbidities and no co-morbidities groups were 170 and 195 respectively. 14 patients (13 with co-morbidities & 1 no co-morbidity) died in total. Results showed that relative risk of persistent PH and subsequent mortality following PE in COVID19 is 4.16 times & 1.32 times more in co-morbidties group as compared to no co-morbidties group respectively (p<0.001) Conclusion(s): Patients with co-morbidities are at high risk of persistent PH and mortality due to PE secondary to COVID19 and should be worked up for CTEPH if PH exist on 3/12 ECHO.
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Background Management of pediatric pulmonary hypertension (PH) may require manipulation of multiple receptor sites to maximize response to medical therapy. Assessment of response typically occurs through imaging, labs, physical exam and recurrent cardiac catheterization, with anesthetic exposure to assess pulmonary artery pressures (PAP) and vascular resistance (PVR). We aimed to assess feasibility, safety and utility of remote PAP monitoring in pediatric PH patients. Methods We reviewed 4 pediatric patients with significant PH, each of whom underwent cardiac catheterization with pulmonary vasoreactivity testing and placement of a CardioMEMS remote PAP monitoring device. Results Four patients (P1-4: ages 5, 6, 8 and 10 years old) underwent CardioMEMS insertion without procedural complication. P1, P2 and P3 presented with unrepaired VSD;ASD with partial anomalous pulmonary venous return;and ASD and PDA, respectively, while P4 had prior repair of atrioventricular canal. Three patients had Down syndrome. All had elevated PAP and PVR. Mean left lower PA branch size was 7 mm. Mean PAP prior to therapy was 70 mm Hg for P1, 82 for P2, 93 for P3 and 30 for P4. All 4 patients required initiation of triple therapy for treatment of PH, with improvement or normalization of PAP by CardioMEMS, which also included surgical or catheter based intervention for 3 patients. Post-repair of P2, he was unable to be separated from cardiopulmonary bypass and was placed on ECMO. Right ventricular cardiac output improved over 2 weeks, with improvement of PAP determined through serial CardioMEMS. He was successfully decannulated, utilizing CardioMEMS in the OR. Two patients also developed COVID respiratory infections at home with CardioMEMS assessments allowing for oxygen and medication titration. Conclusion Remote PAP monitoring is feasible and appears safe in pediatric patients with adequate PA size. It allows for manipulation of medical therapy with real time knowledge of impact on PAP and can augment management during weaning of mechanical cardiac support. It may also augment decision-making in management of PH patients with developmental disabilities in whom traditional assessments may be more challenging.Copyright © 2023 American College of Cardiology Foundation
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Background The COVID-19 pandemic prompted a major surge in telehealth practices, including the increased utilization of remote Pulmonary Artery Pressure (PAP) among cardiologists worldwide. This study aimed to assess the sociodemographic differences in the utilization of the CardioMEMS HF system for remote PAP monitoring in patients with Heart Failure in the USA. Methods The National inpatient sample database of the USA was queried for all patients with HF who received the CardioMEMS HF system between 2016 and 2019. Multiple logistic regression models were subsequently performed to investigate the socio-demographic factors influencing remote pulmonary artery pressure measurements. Results A total of 1540 patients had a CardioMEMS device for remote PAP monitoring between 2016 and 2019. Following a multivariate analysis accounting for potential confounders, we noted that the use of remote PAP was lower in women vs. men (Adjusted odds ratio (AOR): 0.65, CI 0.52 - 0.82, p < 0.001). Patients who lived in low (AOR: 0.38, CI 0.25 - 0.57, p < 0.001), medium (AOR: 0.57, CI 0.40 - 0.82, p = 0.003), and high-income neighborhoods (AOR: 0.60, CI 0.44 - 0.82, p < 0.001), were also less likely to have remote PAP compared to patients who lived in very high-income neighborhoods. There was no racial difference or association between device use and primary insurance payer. Conclusion There are inequities in the utilization of remote PAP monitoring amongst the Heart Failure population within the USA.Copyright © 2023 American College of Cardiology Foundation
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Background: Treprostinil is a prostacyclin analogue which has been approved in the EU for intravenous (i.v.) and subcutaneous (SC) administration in patients with PAH. LIQ861 is a dry powder formulation of treprostinil which can be used for inhalation via a handheld device. Objectives and methods: LTI-201 was a multicentre, Phase 2, open-label, dose-escalation study to evaluate the HD dose-response and safety of LIQ861, followed by an open-label extension period. In "Part A" HD response was measured by right heart catheterization for 120 minutes after a single 26.5 or 53 mug dose of LIQ861. In "Part B" patients were titrated to symptomatic relief (<=159 mug QID) and were reassessed after 16 weeks using right heart catheterization and clinical assessments. Result(s): Fifteen PAH Patients (60 % female, mean age 56 +/- 14.3 years, mean pulmonary vascular resistance (PVR) 605+/-246 dynes/sec/cm-5) were included. In Part A HD measures (PVR and mean pulmonary arterial pressure) improved with a peak response after 15 minutes for both doses. The study was stopped early due to the COVID19 pandemic with only 6 patients completing Part B. At Week 16, these HD responses also improved and clinical assessments improved or remained stable for these patients. All doses of LIQ861 were generally well-tolerated with only one serious adverse event (short episode of hypoxia after inhalation). The most frequently reported adverse events were cough and throat irritation and most were assessed as mild in severity. Conclusion(s): LIQ861 was overall safe and well tolerated. An expected improvement in HD measures was seen with acute and chronic dosing.
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Although it is a rare disease, the number of available therapeutic options for treating pulmonary arterial hypertension has increased since the late 1990s, with multiple drugs developed that are shown to be effective in phase 3 randomised controlled trials. Despite considerable advancements in pulmonary arterial hypertension treatment, prognosis remains poor. Existing therapies target pulmonary endothelial dysfunction with vasodilation and anti-proliferative effects. Novel therapies that target proliferative vascular remodelling and affect important outcomes are urgently needed. There is need for additional innovations in clinical trial design so that all emerging candidate therapies can be rigorously studied. Pulmonary arterial hypertension trial design has shifted from short-term submaximal exercise capacity as a primary endpoint, to larger clinical event-driven trial outcomes. Event-driven pulmonary arterial hypertension trials could face feasibility and efficiency issues in the future because increasing sample sizes and longer follow-up durations are needed, which would be problematic in such a rare disease. Enrichment strategies, innovative and alternative trial designs, and novel trial endpoints are potential solutions that could improve the efficiency of future pulmonary arterial hypertension trials while maintaining robustness and clinically meaningful evidence.Copyright © 2022 Elsevier Ltd
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Background: 49 patients underwent Lung Biopsy due to different indications and Post-COVID Pulmonary Fibrosis(PCPF) was suspected in 25 patients. Objective(s): To document the evidence of PCPF in patients with history of suspected COVID 19 infection (in past oneyear) through Transbronchial Lung Biopsy(TBLB)with flexible bronchoscopy. PFT and HRCT gave variedpresentation. Method(s): we have evaluated patients who underwent Lung Biopsy on flexible Bronchoscopy between 08/07/2021 till31/01/2022 at Metro Hospitals and Heath Institute, Meerut, UP, India. The history of exposure to COVID 19 infectionwas taken. Most of these patients underwent Echocardiography (ECHO) for Left Ventricular Ejection Fraction (LVEF)and Pulmonary Artery Pressure (PAH), Pulmonary Function Test (PFT) and High Resolution CT Scan Chest (HRCTChest). Result(s): 49 patients underwent Lung Biopsy. 25 patients gave the history of exposure to COVID 19 infection with complaint of breathlessness and chest discomfort in the last 1 year. HRCT chest was suggestive of Atelectasis in 3 patients, Interstitial Lung Disease (ILD) in 6, Fibrosis in 8, Pulmonary Nodules in 4 and HRCT was not done in 4 patients. PFT showed Mixed Ventilator Defect in 8, Obstructive in 3, Restrictive in 7, small airway disease in 1 and 6 patients couldn't perform PFT. PAH was normal for 6,mild for 16, moderate for 2 and 1 severe. 4 patients had Coronary Artery Disease. 2 patients had major complications like pneumothorax who underwent TBLB. Conclusion(s): PCPF was detected with the help of TBLB in the patients with history of exposure to COVID 19 infection. However, TBLB may cause major complication like pneumothorax seen in 8% cases.
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Pulmonary hypertension (PH) is a severe disease that can progress to clinical decompensation, risk of hospitalization and death owing to disease-related or other diseases. In the context of coronavirus disease 2019 (COVID-19), PH was considered a risk factor for complications. The purpose of the study was to assess the mortality rate of COVID-19 in PH patients from a PH Center in Brazil. We conducted a telephone survey between June and August 2021 among all patients or relatives from the PH referral center who were followed after the first case of COVID- 19 in Brazil. Only patients with a confirmed diagnosis of PH were included in the analysis. Of the 426 patients followed in the first 18 months of the pandemic, 115 patients were excluded (lost to follow-up, post-acute PE or unconfirmed PH). Among 311 patients included, 39 had a confirmed diagnosis of COVID-19 (COVID-19 + ), and 38.5% of patients were hospitalized. The estimated incidence rate was 12.5%. Comparing the COVID-19+ versus patients without infection (COVID-19 - ) in the period, the mean age was similar (55 +/- 17 vs. 54 +/- 16 years) and the majority in the COVID-19+ group were female (85% vs. 69%, p = 0.039), respectively. There was no difference in the proportion of patients diagnosed with pulmonary arterial hypertension (PAH;49% and 42%) and chronic thromboembolic pulmonary hypertension (CTEPH;24% and 33%) between groups. All PAH patients and the majority of CTEPH patients were treated on specific therapy (combination/triple therapy, 70%). The case fatality rate in the PH-COVID-19+ group was 23%. Considering only PAH and CTEPH, the case fatality rate was 21,9%, while COVID-19 mortality was 2.9% and overall lethality in Brazil was 2.8%. In the COVID-19+ group, the mean pulmonary artery pressure was 48 +/- 14 mmHg, cardiac index 2.7 +/- 0.6 L/min/m2 and pulmonary vascular resistance 730 +/- 424 dyn.s/cm5. In conclusion, among PH patients there was high incidence and mortality from COVID-19, even in those with PHspecific therapy. Further studies are needed to evaluate the prognostic predictors in PH-COVID-19 patients.
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Background and aims: Echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation Vmax/mitral E/e') represents an accurate and sensitive non-invasive tool to estimate trans-pulmonary pressure gradient, showing a sensitivity for pre-capillary pulmonary obstruction higher than traditional echocardiographic measures. The prognostic value of ePLAR in patients with coronavirus disease-2019 (COVID-19) remains unknown. We aimed to investigate the predictive role of ePLAR on mortality in COVID-19 patients. Method(s): One hundred consecutive patients admitted in two Italian institutions for COVID-19 undergoing early echocardiographic examination were included. ePLAR was determined from the maximum tricuspid regurgitation velocity at continuous wave Doppler (m/s) divided by the transmitral E-wave: septal mitral annular Doppler Tissue Imaging e'-wave ratio (TRVmax/E:e'). Main outcome measure was inhospital death. Result(s): Patients who died during hospitalization had a higher prevalence of tricuspid regurgitation, higher ePLAR and right-side pressures, lower Tricuspid Annular Plane Systolic Excursion (TAPSE)/Pulmonary Artery Systolic Pressure (PASP) ratio and reduced inferior vena cava collapse than survivors. Patients with ePLAR >0.28 m/s showed increased in-hospital mortality compared to those having ePLAR <=0.28 m/s (27% vs 10.8%, p=0.05, Figure). A Cox model of multivariate analysis demonstrated that an ePLAR >0.28 m/s was independently associated with increased risk of death (HR 5.07, 95% CI 1.04-24.50, p=0.043), particularly among patients with increased pulmonary arterial pressure. Conclusion(s): A high ePLAR value at baseline predicts in-hospital death in patients with COVID-19, especially in those with elevated pulmonary arterial pressure. These results support an early ePLAR assessment in patients admitted for COVID-19 to identify those at higher risk and potentially to guide strategies of diagnosis and treatment. (Figure Presented).
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SESSION TITLE: Anatomical Cardiovascular Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Scimitar Syndrome is a rare congenital disorder characterized by partial or complete anomalous pulmonary venous drainage to the inferior vena cava, right lung hypoplasia and displacement of the cardiac structures into the right hemi-thorax (1) The name Scimitar Syndrome is derived from the resemblance of the anomalous pulmonary vein to a curved Middle Eastern sword known as a scimitar (1). Some patients experience no symptoms while others may have severe pulmonary hypertension and dyspnea (2) (3). Cases may be discovered in infancy although some patients are not diagnosed until early adulthood. Here we present a case of a woman who was discovered to have symptomatic scimitar syndrome in her teenage years and opted to forego correction. CASE PRESENTATION: Patient was a 38 year old female with past medical history of Scimitar Syndrome who presented to the pulmonary clinic after a short hospitalization with mild COVID-19. Prior to contracting COVID-19 she had experienced worsening dyspnea over one year and now becomes short of breath after walking one half block. Open surgical correction was offered at diagnosis but was not pursued due to patient preference. A CT Angiogram of the chest was performed while she was hospitalized which showed an anomalous right pulmonary vein draining to the hepatic IVC, minimal bilateral patchy opacities and displacement of the heart into the right hemi-thorax. Echocardiography showed normal right ventricular size and function and did not show evidence of pulmonary hypertension. She was referred to the adult congenital heart disease clinic and continued to have severe dyspnea and fatigue. 6 months later, repeat echocardiography and cardiac MRI demonstrated borderline dilation of the right ventricle and atrium but no echocardiographic evidence of pulmonary hypertension. The patient remains hesitant to undergo invasive procedures or interventions. She has been offered a right heart catheterization to better characterize her volume status and obtain direct measurement of her pulmonary artery pressures. DISCUSSION: Although generally discovered in infancy and childhood, Scimitar syndrome may not be discovered until adulthood. Various treatments are available for correction of scimitar syndrome including open surgical approaches with direct implantation of the scimitar vein into the left atrium, trans-catheter occlusion of aorto-pulmonary collaterals and re-routing of the anomalous vein into the left atrium via endoscopic graft placement (4) (6) (7) (8). If left uncorrected worsening left to right shunting and pulmonary hypertension may occur (5). Our patient has developed borderline right ventricular dilation and has experienced severe functional limitation. A right heart catheterization is indicated to determine her pulmonary artery pressures. This case illustrates the potential consequences of deferring early treatment for Scimitar Syndrome CONCLUSIONS:. Reference #1: Frydrychowicz A, Landgraf B, Wieben O, François CJ. Images in Cardiovascular Medicine. Scimitar syndrome: added value by isotropic flow-sensitive four-dimensional magnetic resonance imaging with PC-VIPR (phase-contrast vastly undersampled isotropic projection reconstruction). Circulation. 2010 Jun 15;121(23):e434-6. doi: 10.1161/CIRCULATIONAHA.109.931857. PMID: 20547935 Reference #2: Abdullah A. Alghamdi, Mansour Al-Mutairi, Fahad Alhabshan, Scimitar syndrome: restoration of native pulmonary venous connection, European Heart Journal Supplements, Volume 16, Issue suppl_B, November 2014, Pages B41–B43, https://doi.org/10.1093/eurheartj/suu025 Reference #3: Khan A, Ring NJ, Hughes PD. Scimitar syndrome (congenital pulmonary venolobar syndrome). Postgrad Med J. 2005 Apr;81(954):216. doi: 10.1136/pgmj.2004.027813. PMID: 15811882;PMCID: PMC1743239 DISCLOSURES: No relevant relationships by John Prudenti No relevant relationships by Anthony Smith
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SESSION TITLE: Medications and Pulmonary Rehabilitation in COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The use of inhaled epoprostenol (iEPO) has demonstrated improvement in outcomes for patients with pulmonary hypertension and right heart failure. iEPO has been used as a rescue therapy for acute respiratory distress syndrome (ARDS) and has been shown to improve oxygenation, reduce shunting, and decrease pulmonary artery pressures. However, pulmonary vasodilators do not improve mortality in patients with ARDS. Furthermore, there is currently little data on the efficacy of iEPO via high flow nasal cannula (HFNC) for ARDS patients. Here, we describe our experience with iEPO in our patients with COVID-19-related ARDS on HFNC in a Northern California county hospital. METHODS: From March 2020 to December 2021, 74 patients with COVID-19 infection and related ARDS were placed on HFNC and received iEPO, at a public tertiary care center. A positive response to iEPO was defined as an increase P/F ratio of 10%, increase in PaO2 of 20%, decrease in FiO2, or reduced flow rate within 24 hours of initiation of iEPO. Non-parametric statistics were used to compare groups. RESULTS: 21 women and 53 men with COVID ARDS ranging from 30-86 years of age (mean age 60.1 ± 13.9) received iEPO while on HFNC. The mean hospital length of stay was 36.3 ± 43 days. All patients received steroids and 83.8% received antibiotics. 55.4% of all patients in the study (n=41) progressed to mechanical ventilation and 58.1% (n=43) survived to discharge, mean age 57 ± 14 years. 20.3% (n=15) of patients showed a response to iEPO. Patients who responded to iEPO were significantly less likely to progress to mechanical ventilation (13% vs 66%, p=0.0003) and more likely to survive to discharge (93% vs 49%, p=0.0021). CONCLUSIONS: Among patients with COVID ARDS on HFNC, patients who respond to iEPO are less likely to progress to mechanical ventilation and more likely to survive to discharge. Our study is limited by small sample size and lack of randomization. Use of iEPO in the right subset COVID ARDS on HFNC may improve outcomes. CLINICAL IMPLICATIONS: Patients on HFNC selected for initiation of iEPO had a poor overall prognosis, with 41.9% not surviving to discharge and 55.4% requiring mechanical ventilation. iEPO response correlates with not requiring mechanical ventilation and with increased likelihood of survival to discharge. DISCLOSURES: No relevant relationships by Heng Duong No relevant relationships by Craig Ivie No relevant relationships by Neharika Khurana No relevant relationships by Connie Park No relevant relationships by Natasha Puri No relevant relationships by Adam Thompson No relevant relationships by John Wehner
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SESSION TITLE: The Cardiac Intensivist 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Hydroxychloroquine and chloroquine are medications derived from aminoquinoline. They are disease-modifying antirheumatic drugs used in the treatment of systemic lupus erythematosus (SLE). Although well tolerated, they do have side effects such as retinopathy, vacuolar myopathy, neuropathy, and as seen in our patient, cardiotoxicity. CASE PRESENTATION: Patient is a 48 year old female with a past medical history significant for chronic kidney disease secondary to autosomal dominant polycystic kidney disease, SLE on hydroxychloroquine who presented to the emergency department complaining of weakness. On arrival the patient was found to be in cardiogenic shock. Her transthoracic echocardiogram revealed a reduced ejection fraction of 37% and a large pericardial effusion concerning for tamponade physiology. Her COVID-19 PCR test was positive. She was taken for emergent pericardiocentesis which revealed 300cc of exudative fluid. Patient’s right heart catheterization revealed mean pulmonary capillary wedge pressure of 23 mmHg, pulmonary artery pressures of 44 mmHg/24 mmHg, mean 31mmHg, cardiac index 1.1L/min/m² by thermodilution, 1.7 L/min/m² by Fick. Following right heart catheterization and intra aortic balloon pump placement, the patient was admitted to the medical intensive care unit (MICU) and placed on intravenous inotropic and vasopressor support. Shortly after arrival to the MICU, patient had an increase in vasopressor requirements. Bedside ultrasound revealed cardiac tamponade. Patient had approximately 400cc of bloody pericardial fluid removed from her pericardial drain. The decision was made for emergent venoarterial extracorporeal membrane oxygenation (ECMO) to be initiated. Endomyocardial biopsy was performed which revealed vacuolization in the cytoplasm of several myocytes as well as lymphocytes in the interstitium of the endocardium. The vacuoles found in the cardiac myocytes were PAS positive. These biopsy results are consistent with hydroxychloroquine cardiotoxicity. The patient’s hydroxychloroquine was discontinued. In addition to hemodynamic support, she also received intravenous immunoglobuluin and systemic steroids. After a prolonged hospitalization she was successfully discharged. DISCUSSION: Cardiotoxicity is a rare adverse reaction seen with hydroxychloroquine. A 2018 systematic review revealed 127 cases of cardiac toxicity associated with the use of hydroxychloroquine or chloroquine. Most patients had been treated with the medication for a prolonged period of time and the toxicity is dose dependent. The mechanism behind hydroxychloroquine and chloroquine induced cardiomyopathy is believed to be secondary to lysosomal dysfunction as a result of toxic phospholipid accumulation in cardiomyocytes. CONCLUSIONS: In patients with new onset cardiomyopathy, a detailed medication reconciliation should be conducted to evaluate for toxins such as hydroxychloroquine and chloroquine. Reference #1: Della Porta, A., Bornstein, K., Coye, A., Montrief, T., Long, B., & Parris, M. A. (2020). Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians. The American Journal of Emergency Medicine. Reference #2: Abbi, B., Patel, S., Kumthekar, A., Schwartz, D., & Blanco, I. (2020). A Case of Cardiomyopathy With Long-term Hydroxychloroquine Use. JCR: Journal of Clinical Rheumatology, 26(8), e300. Reference #3: Chatre, C., Roubille, F., Vernhet, H., Jorgensen, C., & Pers, Y. M. (2018). Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature. Drug safety, 41(10), 919-931. DISCLOSURES: no disclosure on file for Joseph Adams;no disclosure on file for Suliman Alradawi;No relevant relationships by George Kalapurakal No relevant relationships by Mohammed Siddiqui
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Introduction: Massive pulmonary embolism is a rare complication following Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) decannulation. Management can be challenging. The authors present a case that required VV-ECMO re-cannulation and catheterdirected thrombolysis. Main body: 58-year-old gentleman, background of hypertension and asthma, admitted with severe respiratory failure secondary to COVID-19 pneumonitis. Due to lack of improvement with conventional ARDS treatment, he was referred and retrieved on VV-ECMO. After being off sweep gas for more than 24 hours he was decannulated on day 7. Five hours after decannulation the patient acutely deteriorated. He became tachycardic, hypotensive and hypoxic. A bedside TTE showed severely dilated and impaired right ventricle. The patient was started on milrinone and nitric oxide. Nevertheless, he deteriorated further and became profoundly hypoxic and hypercapnic, and a decision was made to start him on VV-ECMO. A TOE was done to guide cannulation and showed a thrombus in the RV and in the left pulmonary artery. Next day, a CT-pulmonary angiogram (CTPA) was done which showed saddle-shaped pulmonary embolism, with a large occlusive clot in the left main pulmonary artery causing complete non-perfusion of the left lung. After a multi-disciplinary team discussion, the patient had catheterdirected thrombolysis, with some haemodynamic improvement. Within 48 hours, TTE was repeated showing no significant improvement on RV function. CTPA showed very mild decrease of the clot burden. Decision was made to repeat catheter-directed thrombolysis and partial thrombectomy. Repeated imaging revealed decrease in the size of the left main pulmonary artery thrombus. It is thought that the massive pulmonary embolism could have been caused by showering of ECMO cannulas-related thrombi, which were dislodged during decannulation. Patient remained on VV-ECMO for 32 days and was decannulated successfully afterwards and was discharged home on apixaban and long-term pulmonary hypertension follow-up. Conclusion: ECMO cannulas related thrombi are not uncommon complications because of prolonged stay and coagulopathy related to ECMO circuit. However, massive embolism is rarely seen. The use of echocardiography was paramount on the differential diagnosis. In this TTE study, the right ventricle looks significantly dilated with severely impaired both longitudinal and radial functions. Additionally noted septal flattening in systole indicating RV pressure overload, diastolic notching of RVOT doppler trace consistent with significantly raised pulmonary artery pressure and mild to moderate tricuspid regurgitation. Otherwise, the left ventricle is small and has preserved function. (Figure Presented).
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Introduction: Inhaled nitric oxide (iNO) can be utilized as a rescue treatment option in refractory hypoxaemia and in the potential reversal of pulmonary vascular resistance by pulmonary vasodilation.1 Its use remains controversial due to limited evidence regarding efficacy and potential side effects.2 Furthermore, it requires additional equipment and consumables and its infrequent use means staff may be relatively unfamiliar with the treatment. Objectives: Investigate use of iNO within our adult critical care unit in order to identify potential quality improvements that could be made to the delivery of this therapy. Clarify the proportion of patients who demonstrated a favourable PaO2/FiO2 (PF) response to iNO. Methods: We conducted a single-centre retrospective analysis of consecutive patients treated with iNO on the General & Cardiac Intensive Care Unit at Manchester Royal Infirmary between 01/01/2018 and 25/06/2021. Data was extracted from electronic patient records on patient characteristics, indication for iNO, starting dose, ventilatory characteristics, change in PF ratio and ICU outcome. Results were recorded at iNO initiation, 2, 6, 12 and 24 hours. A responder was defined by improvement in the PF ratio of ≥20% at any point up to 6 hours after initiation. Results: 37 patients were identified, mean age 51 years (SD 14). 84% were male and 16% were female. 27 patients (73%) had a diagnosis of COVID-19 pneumonitis (Figure 1). Primary indication for iNO was acute respiratory failure (ARF) in32 (86%) and right ventricular failure in 5 (14%)patients. Prior to iNO, patients had been in ICU for 11 days (SD 11) and had received invasive mechanical ventilation for 163 hours (SD 188). PF ratios at initiation were 12.8kPa (SD 5.0), in keeping with severe ARDS and 13 (39%) were already proned at initiation. Median troponin result prior to therapy was 21[IQR 14-81]. 12 patients (32%) had ECHO evidence of raised pulmonary artery pressures. A starting dose of 20ppm iNO was observed for each patient. By 6 hours, 14/37 patients (37%) were classified as positive responders. There was a significant increase in PF ratios at 6 hours compared to baseline in responders (15.9kPa vs 12.0kPa, p=0.04) but no significant difference at any other time point. There was no difference in the duration of therapy in responders vs non responders (76 vs 85 hours, p=0.72). Conclusion: iNO therapy may offer short-term improvement in oxygenation in <40% of patients at 6 hours. Duration of therapy was similar regardless of response. This may suggest reluctance to discontinue therapy once started possibly through fear of precipitating deterioration, belief that iNO has halted decline or reluctance to recognize futility when there are few other therapeutic options. iNO is typically commenced when patients have already been invasively ventilated for several days. It is unknown whether earlier initiation would affect response. Use of iNO has increased markedly since the start of the COVID-19 pandemic which should prompt units to evaluate their own practice with this therapy.
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Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P<0.001). A later six months follow-up showed that two out of 12 (16.6%) COVID-19 positive OHT patients died. There was no statistically significant difference between the prevalence of COVID-19 in our patients compared to Iran’s general population (P=251.0). Non-compliance with personal protective protocols and a history of contact with COVID-19 cases were the most risk factors for COVID-19 infection in OHT patients.
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Background: Despite several pharmacological advances, the morbidity and mortality in heart failure (HF) remain high, posing a problem for both patients and the National Health System. The natural history of this disease alternates phases of stability and phases of exacerbation, with a progressive decline in the patient's functional capacity and quality of life;this has led to the development of remote monitoring systems. These devices are emerging as an important tool for the effective HF management, even during the COVID-19 pandemic. Methods: We enrolled 6 patients with end-stage HF, who received the combined CardioMEMS / Levosimendan strategy to reduce the number of hospitalizations and optimize both tailored adjustment of home therapy and infusions of Levosimendan. Specifically, CardioMEMS is a wireless sensor that can be implanted in the pulmonary artery, where it detects cardiac filling pressures, an objective measure of the patient's hemodynamic congestion;these pressures increase two weeks before the onset of symptomatic congestion. Results: The 6 patients (72.25±4.60 years;33.33% female) who received the device did not have any complications related to the procedure. Patients were monitored daily by CardioMEMS;if the cardiologist detected a tendency for pulmonary artery diastolic pressure (PAPd) to rise, patients were contacted for home therapeutic changes. If no further changes were possible, the patient was hospitalized for the infusion of Levosimendan. In particular, following the implantation of CardioMEMS, a significant reduction in HF unscheduled hospital admissions was recorded (hospitalizations / month: pre-CardioMEMS 0.657±0.303 vs post-CardioMEMS 0.029±0.021, p 0.0313) (Figure 1). In addition, lower pulmonary arterial pressures were recorded at 6-months FU on CardioMEMS monitoring (pre vs post: PAPs: 51.25±2.56 vs 42.75±2.46 mmHg, p 0.0168;PAPd: 26.25±0.85 vs 20.25±0.85 mmHg, p 0.0034), a reduction in the echocardiographic E/e' ratio (20.86±1.77 vs 14.13±2.02, p 0.0057), an improvement in the quality of life (EQ5D 75.17±2.06 vs 108.60±8.70, p 0.0078) and a reduction in IL-6 levels (p 0.0211). Conclusions: In this study we present the first experience of serial infusions of Levosimendan guided by CardioMEMS. Our results support the usefulness of this device in remote management of the HF patient, especially during this pandemic.
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The new coronavirus (COVID-19) epidemic caused by SARS-CoV-2 has emerged as perhaps the biggest medical problem of our century. Although COVID-19 mainly affects the lungs, it also affects many organs, especially the cardiovascular system. Pulmonary hypertension (PH) is a pulmonary vascular disease described by pulmonary arterial vasoconstriction and remodeling, which may lead to an increased pulmonary artery pressure with varying clinical course and severity depending on the etiology and eventually to right heart failure. Because of associated comorbidities, patients with PH are likely to face a potential risk of severe complications and mortality and unfortunately, they may have worse outcomes than other patients. The COVID-19 pandemic has brought us new and different challenges in the follow-up and treatment processes of patients with PH. For patients admitting to the hospital, it is important to balance the risk of exposure to COVID-19 with ongoing care and treatment services. However, the COVID-19 outbreak has brought serious challenges to PH centers to weigh the risks and benefits of diagnostic research, including potential exposure to COVID-19, and the timing of initiation of PH-specific treatment in high-risk patients. In this article, the management of PH patients during the COVID-19 pandemic;problems encountered in diagnosis, clinical follow-up and treatment processes;the different difficulties experienced during hospitalizations have been compiled.
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Background: Extracorporeal membrane oxygenation (ECMO) is a form of cardio-pulmonary life support used for patients with respiratory and/or cardiac failure. Hybrid ECMO is a sophisticated circuit to match the exact hemodynamic demands in patients who are refractory to traditional ECMO settings. Case: A 43-year-old male presented with dyspnea for four days. On physical examination, he exhibited increased work of breathing and decreased breath sounds bilaterally. Pulse oximetry was 70% on room air, minimally improved to 75% on maximum high flow nasal cannula. He was found to be COVID-19 positive and demonstrated diffuse bilateral lung consolidation on CT chest consistent with severe acute respiratory distress syndrome. Patient was intubated but continued to show poor oxygenation with P/F ratio of 71 (Normal: >400). Veno-Venous (VV) ECMO was started with cannulations into the right femoral vein (RFV) and right internal jugular vein (RIJV);this resulted in an initial improvement of partial pressure of oxygen (pO2) in arterial blood gas. However, within a few days, pO2 started to decrease with visual evidence of recirculation of oxygenated blood into the venous drainage line. A transthoracic echocardiography revealed severe pulmonary artery (PA) hypertension secondary to respiratory failure with PA pressure of 116mmHg (Normal: 18-25mmHg). This prompted a revision of the ECMO circuit to offload the right ventricle. Revised circuit included a cannula in the RFV for venous drainage and oxygenated venous return through two pathways: cannula in the RIJV (approximately 1 liter return), and a third cannula inserted through the left subclavian vein terminating into the main PA (approximately 4 liters return). Hereon, patient was able to maintain adequate pO2 for the remainder of his hospital stay until he was transferred to a lung transplant center. Conclusion: Our case illustrates the clinical sophistication of hybrid VV-PA ECMO-especially in patients with PA hypertension and impending right-sided heart failure. As respiratory failure secondary to COVID-19 becomes more prevalent, hybrid ECMO may provide a practical solution to protect the right heart in the journey to lung transplant.
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RATIONALE: Advances in PAH management and well-established treatment guidelines have improved the prognosis for patients. However, the extent to which guidelines are implemented in real-world practice and the relationship between guidelines and real-world patient outcomes remain in question. To assess real-world treatment and outcomes, a new type of comprehensive, integrated patient data repository (CIPDR) was created. Here, we describe the process to create this repository to enable interpretation of the collected data. METHODS: The TRIO CIPDR was created with guidance from six pulmonologists who have experience in design of and/or participation in PH registries (e.g. REVEAL). The CIPDR includes data elements of demographics, disease, comorbidities, laboratory data, pulmonary function testing, functional status, PAH treatment, reasons for treatment discontinuation/switch, hospitalizations, and death, which are collected through HIPAA-secure online forms. To minimize entry errors, participating sites received form training and ongoing support, and each form contained logic to identify improbable entries. All data were deidentified prior to storage in secure, redundant servers. The site engagement, data collection forms, data storage, and data output processes were all designed to allow both retrospective and prospective data collection and for near-immediate repository expansion through addition of other PAH-treating centers. Eleven Pulmonary Hypertension Association-certified care centers initially contributed to the CIPDR though two centers were unable to continue participation due to COVID19 impact. Central IRB approval was obtained though many sites independently received approval for the repository protocol by their IRBs. To facilitate enrollment, specialty pharmacy data corresponding to each site were used to identify potential patients and pre-populate qualification forms. Each site reviewed and qualified patients who met repository criteria: age >18 years, prescribed PAH-specific medications, and confirmation of PAH diagnosis by right heart catheterization (mean Pulmonary Arterial Pressure ≥25mmHg, Pulmonary Capillary Wedge Pressure ≤15 mmHg, and Pulmonary Vascular Resistance ≥3.0 Wood Units at rest). The initial data collection included care encounters between Jan 2019 and Dec 2020 and data concerning diagnosis, onset of symptoms, procedures, and laboratory values closest to enrollment. After completion of data collection, all data were reviewed by Trio Health and adjudicated with each site. RESULTS: Of 3200 patients identified as potentially qualified, 1009 were initially enrolled and their retrospective data encompassing 4489 visits collected. Descriptive measures of the repository are presented in the TABLE. CONCLUSION: The Trio CIPDR is an important step forward to uniquely characterize the patient journey ,treatment patterns, and outcomes for patients with PAH.
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ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.