Optimizing Supportive Care in COVID-19 Patients: A Multidisciplinary Approach.

Within just a few months, SARS-CoV-2 has evolved from a virtually unknown pathogen to a leading cause of morbidity and mortality worldwide. As COVID-19 infection can affect multiple organ systems, treating many manifestations and complications requires clinical expertise across the healthcare professional spectrum. Therefore, interprofessional and multidisciplinary collaboration should form the cornerstone of every hospital's COVID-19 management approach. In this manuscript, we discuss the non-microbial management strategies for our COVID-19 inpatient population. Specifically, through an inter-professional and collaborative approach to care delivery, we provide rationale and guidance on prone positioning, oxygen strategies, early mobilization, identifying and treating co-infections, anticoagulation and ensuring appropriate psychological support for patients and their families. It is our hope that these recommendations help supporting clinician management decisions to best care for hospitalized COVID-19 patients in the region and worldwide.

Impact of antiplatelet therapy on clinical manifestations and outcomes of cardiovascular infections.

Despite advances in medical and surgical management, infective endocarditis remains associated with significant morbidity and mortality. Septic embolization to the brain and other organs is one of the most dreaded complications of infective endocarditis. Given the critical role of platelets in bacterial vegetation formation on cardiac valves or cardiac device leads, antiplatelet agents, including aspirin, have recently generated much interest as adjunctive therapies in cardiovascular infections. In this article, we review the published evidence evaluating the role of platelets in the pathogenesis of cardiovascular infections and the rationale for using antiplatelet agents in these infections.

Predictors of mortality in patients with cardiovascular implantable electronic device infections.

Infection reduces survival in cardiovascular implantable electronic device (CIED) recipients. However, the clinical predictors of short- and long-term mortality in patients with CIED infection are not well understood. We retrospectively reviewed all patients with CIED infection who were admitted to Mayo Clinic from January 1991 to December 2008. Survival data were obtained from the medical records and the United Sates Social Security Index. The purported risk factors for short-term (30-day) and long-term (>30-day) mortality were analyzed using univariate and multivariate models. Overall, 415 cases of CIED infection were identified during the study period. The mean follow-up duration for the 243 patients who were alive at the last follow-up visit was 6.9 years. In a multivariate model, heart failure (odds ratio 9.31, 95% confidence interval 2.08 to 41.67), corticosteroid therapy (odds ratio 4.04, 95% confidence interval 1.40 to 11.60), and presentation with CIED-related infective endocarditis (odds ratio 5.60, 95% confidence interval 2.25 to 13.92) were associated with increased short-term mortality. The factors associated with long-term mortality in the multivariate model included patient age (hazard ratio 1.20, 95% confidence interval 1.06 to 1.36), heart failure (hazard ratio 2.01, 95% confidence interval 1.42 to 2.86), metastatic malignancy (hazard ratio 5.99, 95% confidence interval 1.67 to 21.53), corticosteroid therapy (hazard ratio 1.97, 95% confidence interval 1.22 to 3.18), renal failure (hazard ratio 1.94, 95% confidence interval 1.37 to 2.74), and CIED-related infective endocarditis (hazard ratio 1.68, 95% confidence interval 1.17 to 2.41). In conclusion, these data suggest that the development of CIED-related infective endocarditis and the presence of co-morbid conditions are associated with increased short- and long-term mortality in patients with CIED infection.

Impact of prior aspirin therapy on clinical manifestations of cardiovascular implantable electronic device infections.

AIMS: Cardiovascular implantable electronic device (CIED) infection may present as pocket infection or as infective endocarditis (CIED-IE) with vegetation on device leads or heart valves. As aspirin has both anti-inflammatory properties and interferes with platelet aggregation, we hypothesized that ongoing anti-platelet therapy with aspirin may impact clinical and echocardiographic manifestations of CIED infection. METHODS AND RESULTS: We retrospectively reviewed 415 cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Information regarding aspirin use was available in 392 (94.5%) cases and 178 (45%) had received aspirin therapy prior to clinical onset of CIED infection. Although there were no significant differences in pathogen distribution between patients who had received prior aspirin therapy as compared with those who did not, patients on aspirin therapy were less likely to report chills (25% vs. 35%, P = 0.04), sweats (9% vs.18%, P = 0.01), or have peripheral leukocytosis on admission (33% vs. 46%, P = 0.005). Overall, 82 (21%) of 392 patients met the clinical criteria for CIED-IE. Patients on prior aspirin therapy were significantly less likely to have vegetations on CIED leads or heart valves than those who had not received it (15% vs. 26%, P = 0.01). However, despite the lower frequency of CIED-IE in the aspirin group, there was no significant difference (P = 0.97) in the overall survival between the two groups. CONCLUSION: Aspirin therapy prior to onset of CIED infection was associated with a lower likelihood of vegetation formation on CIED leads or heart valves and associated systemic manifestations of infection.

Correlative anatomy for the electrophysiologist, part II: cardiac ganglia, phrenic nerve, coronary venous system.

Cardiac Ganglia, Phrenic Nerve, Coronary Venous System. There is an increasing need for invasive electrophysiologists to appreciate the exact anatomy of the epicardial space and the coronary veins. The location of the epicardial fat, the complementary relationship with the main cardiac veins, and the location of sensitive structures (arteries, phrenic nerve, esophagus) have become required knowledge for electrophysiologists, and accessing the epicardial space with this thorough knowledge of the pericardial sinuses and recesses is essential to allow radiographic correlation during catheter manipulation. In this review, we briefly describe the anatomy of the pericardial space and then discuss the specific correlation for the invasive electrophysiologist, highlighting epicardial access, catheter navigation, and avoidance of collateral injury, with specific attention to the important recesses of the pericardial space, their regional anatomy, and radiographic correlation when navigating catheters to these locations. We also discuss the anatomy of the main cardiac veins in the context of catheter mapping and ablation of the epicardial substrate through the venous system and without subxiphoid pericardial access. In part II of this series we discuss the detailed regional anatomy of the cardiac ganglia, phrenic nerve, and coronary venous system.

Correlative anatomy for the electrophysiologist, Part I: the pericardial space, oblique sinus, transverse sinus.

There is an increasing need for invasive electrophysiologists to appreciate the exact anatomy of the epicardial space and the coronary veins. The location of the epicardial fat, the complementary relationship with the main cardiac veins, and the location of sensitive structures (arteries, phrenic nerve, esophagus) have become required knowledge for electrophysiologists, and accessing the epicardial space with this thorough knowledge of the pericardial sinuses and recesses is essential to allow radiographic correlation during catheter manipulation. In this review, we briefly describe the anatomy of the pericardial space and then discuss the specific correlation for the invasive electrophysiologist, highlighting epicardial access, catheter navigation, and avoidance of collateral injury with specific attention to the important recesses of the pericardial space, their regional anatomy, and radiographic correlation when navigating catheters to these locations. We also discuss the anatomy of the main cardiac veins in the context of catheter mapping and ablation of the epicardial substrate through the venous system and without subxiphoid pericardial access. In Part I of this two-part series, we discuss the regional anatomy of the pericardial space, oblique sinus, and transverse sinus.

Plasma C-terminal pro-endothelin-1 is associated with target-organ damage in African Americans with hypertension.

BACKGROUND: Endothelin-1 (ET-1) is a vasoactive peptide with vasoconstrictor and mitogenic properties. We investigated whether plasma levels of C-terminal pro-ET-1 (CT-proET-1), a newly described stable fragment of the ET-1 precursor, are associated with target-organ damage in hypertension. METHODS: Participants included 981 African Americans (65 ± 9 years, 71% women) and 812 non-Hispanic whites (61 ± 9 years, 54% women) ascertained from sibships with hypertension. We measured plasma CT-proET-1 by an immunoluminometric assay. Measures of target-organ damage included the ankle-brachial index (ABI) and urinary albumin:creatinine ratio (UACR). Multivariable regressions analyses were employed to assess whether plasma CT-proET-1 levels were independently associated with ABI and UACR. RESULTS: In hypertensive African Americans, higher plasma levels of CT-proET-1 were significantly associated with lower ABI (P < 0.01) and higher UACR (P < 0.01). After adjustment for age, sex, body mass index, systolic blood pressure (SBP) and diastolic blood pressure (BP), diabetes, serum glucose, insulin use, estimated glomerular filtration rate (eGFR), history of smoking, total and high-density lipoprotein cholesterol, medication use, and previous history of myocardial infarction (MI) or stroke, higher plasma levels of CT-proET-1 remained significantly associated with lower ABI (P < 0.01) and higher UACR (P = 0.02). In non-Hispanic white hypertensives, higher plasma levels of CT-proET-1 were weakly associated with higher UACR (P = 0.02) and with lower ABI (P = 0.07). After adjustment for the relevant covariates, no statistically significant associations between CT-proET-1 and ABI or UACR were present in whites. CONCLUSIONS: Plasma levels of CT-proET-1 were independently associated with lower ABI and greater UACR in African American but not non-Hispanic white adults with hypertension.

Cardiac calcified amorphous tumor in a patient presenting for ventricular tachycardia ablation: intracardiac echocardiogram diagnosis and management.

Calcified amorphous tumors (CAT) of the heart are rare primary cardiac tumors characterized by heavy myocardial and valve apparatus calcification. The relationship of the entity with ventricular arrhythmia, if any, is unknown. We describe a case of cardiac CAT in a 58-year-old woman with prior cardiac arrest and recurrent ventricular tachycardia who presented for radiofrequency ablation. Pre-ablation intracardiac echocardiogram revealed the characteristic endomyocardial calcific pattern associated with this tumor that precluded catheter manipulation in the left ventricle. The imaging characteristics and management are described.

The anatomy of the coronary sinus venous system for the cardiac electrophysiologist.

Cardiac electrophysiologists' use of the coronary sinus (CS) to map and ablate accessory pathways and implant left ventricular leads has emphasized the need for understanding CS anatomy. In this review, we briefly examine the developmental and radiological anatomy of the CS and discuss in detail the gross anatomy of this cardiac vein. We highlight the correlations of the acquired anatomical knowledge relevant to clinical electrophysiology practice.

Esthesioneuroblastoma metastatic to the thoracic intradural and extradural space.

BACKGROUND CONTEXT: Ethesioneuroblastoma (ENB) is a rare tumor of the olfactory epithelium that has been shown to metastasize mostly to the cervical lymphatics, with only infrequent spread to other locations. We report a rare case of ENB characterized by recurrence and distant metastasis to the T7-T8 intradural and extradural space. PURPOSE: To report a rare case of recurrent ENB metastatic to the thoracic intradural and extradural space. STUDY DESIGN/SETTING: Case report with a review of the literature. METHODS: A 64-year-old man with recurrent ENB presented with chronic pain in the neck, shoulder, and back. His neurologic exam was normal. Computed tomography of the chest showed no pulmonary metastasis and a high-attenuation spinal canal mass at T8 was noted on magnetic resonance imaging. A laminectomy at T7-T8 was performed for resection of a large epidural mass. A tumor was seen penetrating through the dura, and a midline durotomy was performed for resection of a large intradural mass. Frozen section and permanent stains were consistent with metastatic ENB. RESULTS: The postoperative period was uneventful, and included pain management and physical therapy, followed by chemotherapy and radiation. The patient remains free of spinal recurrence 2 years after surgery. CONCLUSIONS: Metastasis of ENB to the spinal column is rare, and of those instances, 80% are localized to the cauda equina. Recurrent ENB metastatic to the thoracic intradural and extradural space is extremely rare, and was successfully treated with surgical resection.