NT-proBNP and D-Dimer in acute decompensated heart failure: assessment of diagnostic accuracy and correlation with echocardiographic parameters.

PURPOSE: Abnormalities in coagulation and inflammation exist in heart failure. This study compares the diagnostic accuracy of NT-proBNP and D-Dimer and the correlation of these biomarkers with echocardiographic parameters in acute decompensated heart failure. METHODS: A retrospective cross-sectional/observational study was performed using 162 patients with acute decompensated heart failure and 253 age-matched controls. Patients were ruled out for a pulmonary embolus by CT or VQ scans. The study protocol was approved by Institutional Review Board, Lubbock, TX. Correlation of NT-proBNP and D-Dimer values was done with echocardiographic parameters. Statistical significance was assumed at p < 0.05. RESULTS: D-Dimer showed a positive correlation with NT-proBNP (r = 0.665, p = 001). The AUC for NT-proBNP, D-Dimer and a combination of D-Dimer plus NT-proBNP were 0.963, 0.928 and 0.982 respectively. The AUC value for D-Dimer versus the combination of D-Dimer and NT-roBNP was not significant (p = 0.21). Correlation of NT-proBNP was significant with the echocardiographic parameters but D-Dimer did not significantly correlate with any of the echocardiographic parameters studied. CONCLUSIONS: Comparison of the AUC values for D-Dimer versus the combination of D-Dimer and NT-proBNP showed no significance suggestive of comparable diagnostic accuracy in the study population. The lack of correlation between D-Dimer and echocardiographic parameters suggests an independent pathophysiological mechanism underlying upregulation of D-Dimer in acute decompensated heart failure. Further systematic studies are needed to define mechanism of D-Dimer increase in heart failure.

Angiotensin II antagonists and gastrointestinal bleeding in left ventricular assist devices: A systematic review and meta-analysis.

Gastrointestinal bleeding (GIB) especially from arteriovenous malformations (AVM) remains one of the devastating complications following continuous-flow left ventricular device (CF-LVAD) implantation. Blockade of angiotensin II pathway using angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) was reported to mitigate the risk of GIB and AVM-related GIB by suppressing angiogenesis. We performed a systematic review and meta-analysis to evaluate the association between ACEI/ARB treatment and GIB in CF-LVAD population. Comprehensive literature search was performed through December 2019. We included studies reporting risk of GIB and/or AVM-related GIB events in LVAD patients who received ACEI/ARB with those who did not. Data from each study were combined using the random-effects to calculate odd ratios and 95% confidence intervals. Three retrospective cohort studies were included in this meta-analysis involving 619 LVADs patients (467 patients receiving ACEI/ARB). The use of ACEI/ARB was statistically associated with decreased incidence of overall GIB (pooled OR 0.35, 95% CI 0.22-0.56, I2 = 0.0%, p < 0.001). There was a non-significant trend toward lower risk for AVM-related GIB in patients who received ACEI/ARB (pooled OR 0.46, 95% CI 0.19-1.07, I2 = 51%, p = 0.07). Larger studies with specific definitions of ACEI/ARB use and GIB are warranted to accurately determine the potential non-hemodynamic benefits of ACEI/ARB in CF-LVAD patients.

Recurrent short-to-shield phenomenon requiring LVAD exchange: a rare complication.

Left ventricular assist device (LVAD) therapy is a common alternative approach for a patient with end-stage heart failure with HeartMate II (HM II) being one of the most common LVAD implants. The short-to-shield (STS) phenomenon is an uncommon drive-line (DL) dysfunction resulted from broken insulator causing an underlying wire to contact a metallic shield in a DL. This leads to a short circuit and a pump stoppage. We reported a case of 66-year-old man status post-implantation of HM II who presented with STS phenomenon. A tear at the distal end of the DL was found, and the patient underwent replacement of the extracorporeal part of DL twice. After the second repair, the pump functioned normally when tested in the hospital but the STS occurred again at home. The patient then underwent LVAD replacement surgery and insulation breach was found at one of the wires in intracorporeal part of the DL. After the surgery, the patient sustained recurrent episodes of STS and had to undergo a third extracorporeal DL repair surgery. Analysis of the removed DL confirmed an insulation breach. The STS has been resolved since then. Our case is unique as it is very rare to sustain another episode of STS shortly after a pump exchange. It also shows that the occurrence of STS can be intermittent and the area of insulation breach can be different from the area of the visualized tear. As a result, closed monitoring after DL repair must be strictly implemented.

Impact of preoperative atrial fibrillation in patients with left ventricular assist device: A systematic review and meta-analysis.

Atrial fibrillation (AF) is a common finding in patients evaluated for left ventricular assist device (LVAD). There is conflicting data regarding the mortality risk as well as the thromboembolic risk in patients with preoperative AF who undergo LVAD implantation. We examined these risks by performing a meta-analysis. We performed a literature search of Pubmed, EMBASE, SCOPUS, and Cochrane from inception to February 2018. The eligible studies were used to compare mortality rate and thromboembolic risk between AF and Non-AF (NAF) groups after LVAD implantation. We obtained 391 articles from our search strategy. Seven retrospective studies were included and accounted for 5823 LVAD patients (AF 1589; NAF 4234). The median follow-up duration ranged from 7-24 months. The pooled analysis revealed a significantly increased risk of mortality in preoperative AF patients who underwent LVAD operation compared to those with NAF (Risk Ratio [RR] 1.16, 95% CI 1.05-1.28, I2 = 0%). Five studies reported thromboembolism events involving 1359 preoperative AF and 3893 NAF patients. The pooled analysis did not show a statistically significant association between risk of thromboembolic event and preoperative AF (Risk Ratio [RR] 1.08, 95% CI 0.86-1.36, I2 = 76.2%). Our study shows that preoperative AF may be associated with a higher mortality rate. This study is limited by the fact that the data are pooled from retrospective studies. Further prospective studies are warranted in order to validate these results.

Impact of chronic total occlusion on ventricular arrhythmia and mortality in ischaemic cardiomyopathy patient with implantable cardiac defibrillator: a meta-analysis.

Background: Recent studies suggested that chronic total occlusion of the coronary artery increased risk of ventricular arrhythmia (VA) and all-cause mortality in ischaemic cardiomyopathy (ICM) patient who underwent implantable cardiac defibrillator (ICD) implantation. We aim to demonstrate an association between a presence of CTO and poor cardiovascular outcome in ICD implanted ICM patients. Objective: To examine the association between the presence of CTO and all-cause mortality in ICM with ICD implantation Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to February 2018. The studies that reported appropriated shock and all-cause mortality in ICD implanted ICM patients, compared between patients with and without CTO of the coronary artery, were included for meta-analysis. Results: Five studies from 2015 to 2018 were included in this meta-analysis involving 1,095 subjects (505 CTO and 590 non-CTO). The presence of CTO was associated with increased incidence of VA (pooled risk ratio = 1.75, 95% confidence interval: 1.10-2.77, p = 0.01) and all-cause mortality (pooled risk ratio = 1.63, 95% confidence interval: 1.10-2.41, p = 0.001) in ICD implanted ICM patients. Conclusions: Presence of CTO of the coronary artery increased risk of VA and all-cause mortality in ICD implanted ICM patients up to 75% and 63%, respectively. Our study suggested that CTO is an independent predictor of unfavourable outcome and revascularised option should be considered in ICM patients with ICD.

Gastrointestinal Polyps and Hemorrhage as a Presentation of Primary Systemic Light Chain Amyloidosis.

Light-chain amyloidosis is caused by deposition of immunoglobulin light chains within multiple organs, including the gastrointestinal (GI) tract. Gastrointestinal hemorrhage is a less frequent presentation. Endoscopic findings are nonspecific, and bleeding mucosal polyps are rare. We report a 59-year-old Hispanic woman with a history of gastric polyps who presented with recurrent GI hemorrhage from mucosal polyps. She had periorbital purpura and macroglossia. Biopsy of the gastric polyp confirmed amyloid deposition. Bonemarrow biopsy revealed plasma cell myeloma. She was treated with endoscopic intervention and arterial embolization to control the bleeding, and with chemotherapy for multiple myeloma.

Low-dose basiliximab induction therapy in heart transplantation.

We prospectively studied efficacy and safety outcomes of two 10-mg doses of intravenous basiliximab on day 0 and day 4 for induction therapy in 17 consecutive de novo heart transplant recipients. By the 2-week assessment post-transplant, there were no deaths, graft failures, or acute cellular rejections (ACRs) ISHLT grade ≥ 2R. By the 1-year assessment post-transplant, there were 1 (6%) infectious death, no graft failures, 2 (12%) grade 2R ACRs, 6 (35%) asymptomatic cytomegalovirus (CMV) infections, and 4 (25%) treated infections. Our study was the first to show that low-dose basiliximab induction in heart transplant resulted in favorable efficacy and safety outcomes. Additionally, calcineurin inhibitor (CNI) initiation in a low-risk population could be safely delayed using the strategy of modified low-dose postoperative basiliximab. This strategy also appears to allow subsequent early corticosteroid wean, although with the concomitant maintenance of higher CNI levels and higher dosing of mycophenolate.

Surgical prophylaxis with gentamicin and acute kidney injury: a systematic review and meta-analysis.

BACKGROUND: Gentamicin has been increasingly used instead of cephalosporins for surgical prophylaxis in an attempt to reduce the rate of "Clostridium difficile" infection. There are limited data regarding nephrotoxicity related to gentamicin in these patients. METHODS: We have conducted a systematic review and meta-analysis to evaluate the risk of acute kidney injury (AKI) in gentamicin-containing surgical prophylactic regimens, compared to regimens without gentamicin, in several types of surgery. Electronic searches were performed using PubMed and Embase, including terms for "AKI, gentamicin, and surgical prophylaxis" with and without MeSH/EMTREE functions. Statistical analysis was then performed using a random-effect model; risk ratios (RR), risk differences (RD) and heterogeneity (I2) were calculated. Funnel plot was used for assessment of publication bias. RESULTS: Eleven studies with fifteen cohorts with 18,354 patients were included in the analysis. Subgroup analysis was performed according to surgery type. We have found that antibiotic prophylaxis with gentamicin containing regimen has significant risk for developing postoperative AKI in orthopedic surgery (RR 2.99; 95% CI: 1.84, 4.88). The results were inconclusive in other types of surgery. Funnel plot indicates potential publication bias. CONCLUSIONS: Gentamicin-induced AKI is significant in patients undergoing orthopedic surgery. Physicians should consider risks and benefits of using this regimen in individual patients.

Acute Amiodarone Pulmonary Toxicity After Surgical Procedures.

Amiodarone can cause toxicity in several organs, including amiodarone-induced pulmonary toxicity which is a subacute or chronic complication. Amiodarone-induced acute respiratory distress syndrome (ARDS) in postoperative patients is a rare acute complication. The PubMed and Google Scholar databases were searched. Seven retrospective and prospective case series and 10 case reports of amiodarone-induced postoperative ARDS were reviewed. All patients received amiodarone chronically or during the perioperative period. Forty-three out of 285 patients (15%) reported in the retrospective and prospective studies developed amiodarone-induced ARDS. Most of the patients were men in age group 60-80 who had undergone cardiothoracic surgery. All patients had general anesthesia and exposure to high concentrations of oxygen. The onset of symptoms ranged from 2 hours to 2 weeks after surgery. The mortality rate of amiodarone-induced ARDS after surgery was approximately 10%. Ten case reports were evaluated using Naranjo criteria. Two cases had definite amiodarone toxicity, and 8 had probable toxicity based on these criteria. The incidence of amiodarone-induced postoperative ARDS was approximately 15% in these studies. Most operations involved cardiothoracic surgery. Elderly patients on high-dose and long-term amiodarone treatment were at increased risk. This diagnosis is challenging owing to the lack of definite diagnostic criteria; careful clinical evaluation and early drug withdrawal may reduce the severity of this complication.

Percutaneous gallbladder aspiration for acute cholecystitis.

Early cholecystectomy for patients with acute cholecystitis may not be possible in some clinical settings. Percutaneous gallbladder aspiration (PGBA) offers an alternative approach, but the benefits and risks of this procedure are unclear. We synthesized data on the outcomes of PGBA in acute cholecystitis patients using data sources from online databases, including MEDLINE and EMBASE, and bibliographies of included studies from January 2000 through December 2015. Two reviewers independently reviewed and critiqued the quality of each study. Seven eligible studies met our criteria. The success rates in single PGBA and repetitive PGBA (2-4 times) were 50% to 93% and 76% to 96%, respectively. Complication rates were 0% to 8% and were unrelated to the size of needle gauge used for aspiration and the number of aspirations. Salvage percutaneous cholecystostomy (PC) and urgent surgery were required in 0% to 43% of patients and 0% to 4% of patients, respectively. Two studies with antibiotic instillation had clinical success rates of 95% and 96%. In conclusion, repetitive PGBA combined with antibiotic instillation and salvage PC are useful alternatives to early cholecystectomy in patients with acute cholecystitis.

Streptococcus agalactiae pyomyositis in diabetes mellitus.

Pyomyositis is an acute infectious disorder affecting the skeletal muscle. Although seen more commonly in the tropics, cases are being reported in temperate countries, including the United States. We report a case of nontropical pyomyositis in a 58-year-old diabetic man who presented with a vague chest wall swelling. His initial clinical presentation and imaging findings suggested an intramuscular hematoma. He later developed fever with increased swelling, and pyomyositis was diagnosed after an aspiration of the swelling yielded Streptococcus agalactiae. Aspiration of the abscess and the use of appropriate antibiotics led to complete resolution of the disease. We discuss possible factors in diabetics that might predispose them to pyomyositis.

Cardiac Arrhythmias and Abnormal Electrocardiograms After Acute Stroke.

Cardiac arrhythmias and electrocardiogram (ECG) abnormalities occur frequently but are often underrecognized after strokes. Acute ischemic and hemorrhagic strokes in some particular area of brain can disrupt central autonomic control of the heart, precipitating cardiac arrhythmias, ECG abnormalities, myocardial injury and sometimes sudden death. Identification of high-risk patients after acute stroke is important to arrange appropriate cardiac monitoring and effective management of arrhythmias, and to prevent cardiac morbidity and mortality. More studies are needed to better clarify pathogenesis, localization of areas associated with arrhythmias and practical management of arrhythmias and abnormal ECGs after acute stroke.

Effect of N- and T-type calcium channel blocker on proteinuria, blood pressure and kidney function in hypertensive patients: a meta-analysis.

The combination of a calcium channel blocker (CCB) and a blocker of the renin-angiotensin-aldosterone system (RAAS) is recommended in clinical practice guidelines. L/N- and L/T-type CCBs might provide an additional effect on lowering proteinuria. Therefore, we conducted a meta-analysis to assess the efficacy of L/N- and L/T-type CCBs in hypertensive patients with proteinuria. We searched MEDLINE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for single-arm studies and randomized controlled trials (RCTs) that examined the effect of L/N- and L/T-type CCBs as add-on therapy compared with standard antihypertensive regimen for proteinuria on hemodynamic and kidney-related parameters in hypertensive patients with proteinuria. Random-effect model meta-analyses were used to compute changes in the outcomes of interest. We identified 17 RCTs, representing 1905 patients. By meta-analysis, L/N- and L/T-type CCB add-on therapy did not yield significant changes in systolic and diastolic blood pressure compared with standard treatment, but there was a significant lowering of the pulse rate. However, L/N- and L/T-type CCBs resulted in a significant standardized net decrease in albuminuria and proteinuria (-1.01; 95% confidence interval (CI), -1.78 to -0.23; P=0.01), and a standardized net improvement in the estimated glomerular filtration rate and serum creatinine (0.23; 95% CI, 0.11 to 0.35, P<0.001; and -0.25; 95% CI, -0.46 to -0.03; P=0.02, respectively). Despite no additional lowering effect on blood pressure, L/N- and L/T-type CCBs combined with a blocker of the RAAS provided a decrease in proteinuria and improvement in kidney function. Further studies are required to establish the long-term kidney benefits of this combination therapy.

Associated immunological disorders and cellular immune dysfunction in thymoma: a study of 87 cases from Thailand.

Several immune disorders are often associated with thymoma. The aim of this study was to analyze the correlation between clinicopathological features of Thai patients with thymoma and concomitant immune-mediated diseases. Medical records of 87 patients diagnosed with thymoma during a 10-year period were retrospectively reviewed. Peripheral blood T cell subsets along with cytokine responses in 15 thymoma patients and 15 healthy controls were comparatively analyzed. The results demonstrated that thymoma type AB and B2 were the most common types among patients diagnosed with thymoma. The most common presentation was incidentaloma, followed by local chest symptoms and autoimmune diseases. The prevalence of autoimmune diseases, immunodeficiency states, and secondary neoplasms was 34.5, 10.3, and 10.3 %, respectively. Autoimmune diseases were most frequently found in thymoma type B2 and sometimes associated with clinical immunodeficiency, although classic Good's syndrome was rare. Patients with thymoma had significantly lower percentage CD4(+ve) T cells and interferon γ response, but higher percentage regulatory T cells than those in healthy controls. This study indicated that the aberrant immunologic disorders comprising autoimmune diseases, immunodeficiency states, and secondary neoplasms were found in almost 40 % of Thai patients with thymoma and possibly related to defectiva cytokine responses and altered T cell subsets.