Novel Use of the Penumbra CAT 12 Lightning Aspiration System for the Treatment of a Complex Thrombus.

Debulking procedures using aspiration devices have been previously described in the literature to treat vegetations or thrombi on intracardiac structures such as the tricuspid valve. Transcatheter therapy has also been shown to be an effective alternative to surgical treatment for managing high risk or non-surgical patients. Furthermore, aspiration procedures can help identify the unique etiologies of intracardiac masses which can greatly impact differing treatment modalities. Utilization of aspiration devices combined with blood-loss limiting technologies have led to an increased interest in using aspiration systems to address a wider array of clinical situations that can occur. Herein we describe our experience in using the Penumbra CAT 12 Lightning Aspiration System in addressing and treating a mobile mass attached to the lead of an implantable cardiac device.

A dilemma of hemorrhage vs thrombosis: a case of watchman device thrombus in a patient with intracranial hemorrhage history.

Recently updated guidelines for Atrial Fibrillation (AF) outline that percutaneous left atrial appendage (LAA) occlusion with the Watchman device may be a reasonable alternative for those who have contraindications to long-term oral anticoagulation. However, optimal periprocedural antithrombotic therapy remains disputable, particularly in patients who are ineligible for oral anticoagulation or those with history of intracranial hemorrhage (ICH). We present the case of a 67-year-old male with a history of ischemic stroke with hemorrhagic conversion and permanent AF, who was treated with the Watchman device and subsequently developed device related thrombus and recurrent ischemic stroke. We discuss the dilemma and review the literature regarding anticoagulation for device related thrombus in this patient with increased bleeding risk, given his history of ICH. His course and antithrombotic strategy are described and despite the use of anticoagulation with warfarin in the setting of recurrent ischemic stroke, he did not develop hemorrhagic transformation. He also did, ultimately, achieve device related thrombus resolution on repeat Transesophageal Echocardiogram (TEE). This case supported the use of warfarin for device related thrombus in the setting of ischemic stroke and history of ICH. However, evidence-based guidelines for periprocedural antithrombotic regimens in patients with high bleeding risk have yet to be released and further research is needed.

Dermatologic Conundrum: A Cardiac Condition Masqueraded as a Dermatologic Distraction.

A 38-year-old male presented to the emergency department (ED) complaining of extreme pain and a petechial rash on the left ankle for two weeks associated with generalized fatigue, intermittent fevers, and weight loss. He was discharged home from the ED on pain medications. He returned a few days later with a progressive rash that involved the entire left lower extremity to the level of the knee. He was diagnosed with herpes zoster (shingles) and was prescribed acyclovir and steroids. After several days, the patient presented for the third time to the ED. He developed a right lower extremity discomfort this time. The pain in bilateral lower extremities had become unbearable. His cardiac examination revealed a systolic murmur at the apex and a faint diastolic murmur at the left sternal border. Ultimately, he had an echocardiogram that demonstrated both a bicuspid aortic valve and large vegetation on the anterior leaflet of the mitral valve, and his blood culture grew Streptococcus mitis and Streptococcus oralis. The patient was subsequently diagnosed with subacute bacterial endocarditis thought to be sourced from his poor dentition. The diagnosis of infective endocarditis is often delayed due to its nonspecific clinical presentations. Our case displays an unusual skin manifestation of IE that may be present in the absence of other signs and symptoms of the disease.

False activation of the cardiac catheterization laboratory: The price to pay for shorter treatment delay.

INTRODUCTION: In patients with acute ST elevation myocardial ischemia (STEMI), national efforts have focused on reducing door-to-balloon (D2B) times for primary percutaneous coronary intervention (PCI). This emphasis on time-to-treatment may increase the rate of inappropriate cardiac catheterization laboratory (CCL) activations and unnecessary healthcare utilization. To achieve lower D2B times, community hospitals and EMS systems have enabled emergency medical technicians (EMTs) and emergency department (ED) physicians to activate the CCLs without immediately consulting a cardiologist. OBJECTIVE: The purpose of this study is to determine the rate and main causes of inappropriate activation of the CCL which will aid in finding solutions to reduce this occurrence. METHOD: This is a retrospective study, based on an electronic medical system review of all inappropriate CCL activation who presented to Providence Hospital and Medical Centers (PHMC) in Michigan, from January 2015 to July 2016. RESULTS: The CCL was activated 375 times for suspected STEMI. The false STEMI activation was identified in 47 patients which represents 12.5% of total CCL activation. The vast majority of this false activation was due to non-diagnostic electrocardiogram (ECG) that did not meet the STEMI criteria. CONCLUSION: The subjective interpretation of the ECG by EMTs and ED physicians tend to show a wide variability, which may lead to higher-than-anticipated false activation rates of up to 36% in one study. Some studies had reported that up to 72% of inappropriate activations were caused by ECG misinterpretations. These false activations have ramifications that lead to both clinical and financial costs.

Real-world use of PCSK9 inhibitors: A single-center experience.

OBJECTIVE: Hyperlipidemia is an important risk factor for atherosclerotic cardiovascular disease. Many patients are intolerant to or have limited benefit from statins. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been approved for treating hyperlipidemia in these patients. We sought to investigate the impact of these medications in a real-world cardiology practice. METHODS: This was a retrospective study of 17 patients with either heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease with low-density lipoprotein cholesterol (LDL-C) levels above the treatment target despite maximally tolerated statins. Baseline lipid profile was compared with a repeat lipid profile obtained 4 to 6 weeks after initiating treatment with a PCSK9 inhibitor. RESULTS: The average duration of PCSK9 inhibitor treatment was 10.7 months. Lipid profile comparison showed that total cholesterol decreased from 243 ± 72 to 148 ± 39 (mg/dL) (39% reduction), triglycerides decreased from 185 ± 86 to 149 ± 62 (mg/dL) (19.5% reduction), high-density lipoprotein cholesterol increased from 56 ± 20 to 62 ± 26 (mg/dL) (10.7% increase), and LDL-C decreased from 154 ± 30 to 57 ± 32 (mg/dL) (63% reduction) from baseline. CONCLUSIONS: PCSK9 inhibitors as add-on therapy to maximally tolerated statins resulted in an approximately 63% reduction in LDL-C.

Is symptom to balloon time a better predictor of outcomes in acute ST-segment elevation myocardial infarction than door to balloon time?

INTRODUCTION: Current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommend early revascularization with a door-to-balloon (D2B) time of 90 minutes or less in patients undergoing primary percutaneous coronary intervention (PPCI). The focus of most studies has been D2B time. Because of the large variability in the time between symptom onset and presentation, we sought to determine the effect of symptom-to-balloon (S2B) time on presentation and outcomes as a potentially more clinically relevant parameter. METHODS: We conducted a retrospective study of 106 patients who were diagnosed with an acute STEMI, had a documented S2B time and who underwent a PPCI at a tertiary hospital from the period of January 2014 to December 2014. S2B time was defined as the time interval beginning from the episode of chest pain that led the patient to present to the emergency department to the time of the first balloon inflation. We categorized our patients into 2 main groups depending on whether S2B time was greater or less than 240 minutes. They were further subdivided into 2 groups depending on the site of the culprit lesion (left anterior descending LAD vs. non-LAD). RESULTS: There was no difference between the two main groups in regard to the left ventricular ejection fraction (EF) on presentation, length of stay, and readmission with heart failure or chest pain. However, when S2B time was greater than 240 min, there was a statistically significant difference in left ventricular ejection fraction (EF) between LAD and non-LAD stenosis with a mean of 38.4% and 49.3% respectively (P=0.01). No relationship was found between S2B time and gender or age. CONCLUSION: Although D2B time is a well-established clinical parameter, S2B time may be expected to be a more accurate predictor of outcomes. However, in our study, S2B time of >240 minutes only predicted a significant worse EF (and presumably mortality) when the culprit vessel was the LAD. Further studies are needed to better elucidate the relation of S2B time to clinical outcomes.

Arteriolar vs. valvular thrombosis: Pick your evil!

BACKGROUND: Anticoagulation therapy for mechanical prosthetic valves is limited to vitamin K antagonists, unfractionated heparin and low-molecular-weight-heparin. Other forms of anticoagulation are either contraindicated or have not been well studied. Hence, anticoagulation for preexisting mechanical valves is controversial if vitamin K antagonists are contraindicated. We present a case involving an end-stage-renal disease patient with both mitral and aortic mechanical valves who developed warfarin-induced calciphylaxis. CASE PRESENTATION: A 72-year-old male with history of end-stage renal disease, chronic atrial fibrillation and rheumatic heart disease status post mitral and aortic valve replacements presented with complaints of left thigh erythema with skin induration. Despite multiple antibiotic regimens for presumed cellulitis, the skin lesions progressed to necrotic ulcers. A biopsy revealed evidence of calciphylaxis; a lethal condition typically associated with renal disease. The patient was on warfarin for anticoagulation of his mechanical heart valves as well as prophylactically for atrial fibrillation. Warfarin contributes to the development of calciphylaxis and needed to be exchanged to avoid progression of the ulceration. The only other acceptable option for long-term anticoagulation was subcutaneous unfractionated heparin but this approach was not taken. The patient suffered from further sequelae of calciphylaxis and eventually expired. CONCLUSION: Calciphylaxis is a rare, serious disorder that presents with skin ischemia and necrosis mainly in end-stage renal disease patients. The pathogenesis and treatment are poorly understood and the prognosis remains grave. It is proposed that certain medications, including warfarin, contribute to its evolution. The optimal anticoagulation therapy in those with concomitant warfarin-induced calciphylaxis and mechanical valves is undetermined. Further studies are essential to establish new anticoagulation regimens in these devastating circumstances.

Off label use of direct oral anticoagulants for left ventricular thrombus. Is it appropriate?

A 57 year old gentleman with a history of non-ischemic cardiomyopathy and paroxysmal atrial fibrillation presented with worsening lower extremity edema and dyspnea on exertion. He had been compliant with his medications including rivaroxaban (Xarelto) for atrial fibrillation that he takes with the evening meal daily. His echocardiogram showed an ejection fraction of 10-15% and a new left ventricle (LV) apical thrombus. During his hospital stay, he developed right sided weakness. Magnetic Resonance Imaging showed a subacute infarct involving the left parietal lobe. The decision was made to discontinue rivaroxaban and initiate heparin infusion instead. Meanwhile, the patient's neurological symptoms were closely monitored. The patient was then transitioned to warfarin. He was eventually transferred to the rehabilitation floor with minimal residual neurologic weakness. Left ventricular thrombus is an important complication in the setting of systolic dysfunction. The combination of blood stasis, endothelial injury and hypercoagulability, is a prerequisite for in-vivo thrombus formation. The slow onset of action and reversal, need for frequent monitoring, narrow therapeutic range, dietary restrictions, and multiple drug interactions limit the use of vitamin K antagonists. Direct-acting oral anticoagulants (DOACs) do not have these limitations and may also reduce the risk of hemorrhagic stroke. Our patient developed an LV thrombus while on uninterrupted DOAC therapy.

Home Telemedicine in Heart Failure: A Pilot Study of Integrated Telemonitoring and Virtual Provider Appointments.

Congestive heart failure is a significant cause of hospitalization, rehospitalization, and death. Reducing hospital readmission rates is a national priority. Various telemonitoring devices and programs have been developed to help meet this goal. The Health Connect system incorporates monitoring of physiologic data with regular virtual provider appointments. The Health Connect system integrates traditional telemedicine with virtual provider appointments. Virtual appointments empower patients to advocate for their own health by providing numerous opportunities for education and feedback. In addition to early identification of impending decompensation, virtual appointments allow providers to address noncompliance, which is a major factor driving poor outcomes. Further research is required to confirm the benefit of the Health Connect system.

Timing for pacing after acquired conduction disease in the setting of endocarditis.

A 53-year-old gentleman with a history of a mechanical aortic valve presented to the emergency department complaining of a sudden right-sided abdominal pain. He was found to have atrioventricular dissociation on his initial electrocardiogram and his blood cultures grew Streptococcus viridans. The suspicion for endocarditis with periaortic abscess was high so a transthoracic echocardiogram was performed and showed a mass in the left ventricular outflow tract. For better visualization, a transesophageal echocardiogram was recommended and revealed a bileaflet mechanical aortic valve with perivalvular abscess and valvular vegetation as well as severe eccentric paravalvular aortic regurgitation. After sterilization, the patient underwent a successful surgery. Postoperatively, he remained in complete heart block and a permanent pacemaker placement was performed after complete sterilization. He tolerated the procedure well and was discharged home in a stable condition. Perivalvular abscess is one of the most common cardiac complications of infective endocarditis and is associated with an increased risk of mortality. It is imperative to have appropriate treatment guidelines established. However, because of the relative nature of the disease process and the acuity at which intervention needs to be done, a true assessment of the duration of antibiotic therapy prior to surgical intervention, timing of pacemaker placement, and the type of pacemaker is controversial.