bluuebunny/crossref_metadata_2025 huggingface dataset:
Geographically distributed longitudinal nitrogen dioxide and other air pollution sensor measurements in the Avon Longitudinal Study of Parents and Children cohort catchment area
Authors: Johnson Leigh , Thomas Richard , Vande Hey Joshua , Hansell Anna , Gulliver John , Taylor Caroline M. , Golding Jean , Macleod John , Boyd Andy
Published: October 2019

Longitudinal cohort studies provide unique opportunities to investigate the health impact of air pollution. We aimed to enhance the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort study through the systematic collection of routinely monitored air pollution data collected by local authorities and the Department for Environment, Food and Rural Affairs (DEFRA) using a range of sensor technologies. These sensor data are in themselves not well suited for population epidemiology, rather these data are primarily used for validating and calibrating modelled air pollution concentration data over study areas. In this data note we describe the sources of routine air pollution monitoring data and detail data of pollutants including nitrogen dioxide, nitric oxide, nitrogen oxides, particulate matter, benzene and ozone collated from the local authorities that overlap the ALSPAC catchment area (Bristol, North Somerset, South Gloucestershire and part of Bath and North East Somerset).
Negligible heritability of language laterality assessed by functional transcranial Doppler ultrasound: a twin study
Authors: Bishop Dorothy V.M. , Bates Timothy C.
Published: October 2019

Background: It is widely assumed that individual differences in language lateralisation have a strong genetic basis, yet prior studies show low heritability (around 0.25) for the related trait of handedness, and two twin studies of structural brain asymmetry obtained similarly low estimates. This report describes heritability estimates from a twin study of language laterality and handedness phenotypes.

Methods: The total sample consisted of 194 twin pairs (49% monozygotic) aged from 6 to 11 years. A language laterality index was obtained for 141 twin pairs, who completed a protocol where relative blood flow through left and right middle cerebral arteries was measured using functional transcranial Doppler ultrasound (fTCD) while the child described animation sequences. Handedness data was available from the Edinburgh Handedness Inventory (EHI) and Quantification of Hand Preference (QHP) for all 194 pairs. Heritability was assessed using conventional structural equation modeling, assuming no effect of shared environment (AE model).

Results: For the two handedness measures, heritability estimates were consistent with prior research: 0.23 and 0.22 respectively for the EHI and QHP. For the language laterality index, however, the twin-cotwin correlations were very close to zero for both MZ and DZ twins, and the heritability estimate was zero.

Conclusions: A single study showing negligible heritability for language laterality cannot rule out a genetic effect on language lateralisation. It is possible that the low twin-cotwin correlations were affected by noisy data: although the split-half reliability of the fTCD-based laterality index was high (0.85), we did not have information on test-retest reliability in children, which is likely to be lower. We cannot rule out the possibility that true heritability of differences in language lateralization is non-zero, but results indicate that the heritability of this trait is low at best. Stochastic variation in neurodevelopment appears to play a major role in determining cerebral lateralisation.
Environmental Effects on Nonlocal Correlations
Authors: Guha Tamal , Bhattacharya Bihalan , Das Debarshi , Bhattacharya Some Sankar , Mukherjee Amit , Roy Arup , Mukherjee Kaushiki , Ganguly Nirman , Majumdar Archan S.
Published: October 2019

Environmental interactions are ubiquitous in practical instances of any quantum information processing protocol. The interaction results in depletion of various quantum resources and even complete loss in numerous situations. Nonlocality, which is one particular quantum resource marking a significant departure of quantum mechanics from classical mechanics, meets the same fate. In the present work we study the decay in nonlocality to the extent of the output state admitting a local hidden state model. Using some fundamental quantum channels we also demonstrate the complete decay in the resources in the purview of the Bell–Clauser–Horne–Shimony–Holt inequality and a three-settings steering inequality. We also obtain bounds on the parameter of the depolarizing map for which it becomes steerability breaking pertaining to a general class of two qubit states.Quanta 2019; 8: 57–67.
Parallels between stream and coastal water quality associated with groundwater discharge
Authors: McKenzie Tristan , Dulai Henrietta , Chang Jennet
Published: October 2019

Groundwater-surface water interactions drive water quality in both streams and the coastal ocean, where groundwater discharge occurs in streams as baseflow and along the coastline as submarine groundwater discharge (SGD). Groundwater contributions to streams and to the coastal ocean were quantified in three urban streams in Kāne’ohe Watershed, Hawai’i. We used radon as a groundwater tracer to show that baseflow contributions to streams ranged from 22 to 68% along their reaches leading to the coast of Kāne’ohe Bay. Total SGD was 4,500, 18,000, and 23,000 m3/day for the northwest, central, and southern sectors of the bay, respectively. Total groundwater (stream baseflow + SGD) dissolved nutrient fluxes were significantly greater than those sourced from stream surface runoff. The studied streams exhibited increasing nutrient levels downstream from groundwater inputs with high nutrient concentrations, negatively impacting coastal water quality. SGD dynamics were also assessed during the anomalously high perigean spring tides in 2017, where SGD was four times greater during the perigean spring tide compared to a spring tide and resulted in strong shifts in N:P ratios, suggesting that rising sea level stands may disrupt primary productivity with greater frequency. This study demonstrates the importance of considering baseflow inputs to streams to coastal groundwater budgets and suggests that coastal water quality may be improved through management and reduction of groundwater contaminants.
Gold standard method in testing laboratories: Is it appropriate or a misconception?
Authors: Bin Salem Samara , Jagadeesan Premanandh
Published: October 2019

Gold standard is a very common but most powerful terminology amongst diagnostic and analytical laboratory scientists. The genesis dates back to 19th century monetary system where the standard economic unit of account is based on a fixed quantity of gold and has nothing to do with science. Nevertheless, this term had taken an indispensable place in the testing arena ever since its appearance in reputed scientific journals. Application of this term in analytical science from both proponents and opponents perspective has been discussed in detail. Its applicability with regards to bacteriological culture and pulsed field gel electrophoresis for typing bacteria and clinical diagnosis as examples are presented. In conclusion, diagnostic and analytical test methods should not be described or presented in a misleading manner as it is likely to create an erroneous impression on the use of such terminology. We need to revisit gold standard terminology for its appropriation.
Delayed Gastric Emptying Associates With Diabetic Complications in Diabetic Patients With Symptoms of Gastroparesis
Authors: Parkman Henry P. , Wilson Laura A. , Farrugia Gianrico , Koch Kenneth L. , Hasler William L. , Nguyen Linda A. , Abell Thomas L. , Snape William , Clarke John , Kuo Braden , McCallum Richard W. , Sarosiek Irene , Grover Madhusudan , Miriel Laura , Tonascia James , Hamilton Frank A. , Pasricha Pankaj J. ,   for the NIDDK Gastroparesis Clinical Research Consortium (GpCRC)
Published: October 2019

OBJECTIVES:

Diabetic gastroparesis (Gp) occurs more often in type 1 diabetes mellitus (T1DM) than in type 2 diabetes mellitus (T2DM). Other diabetic end-organ complications include peripheral neuropathy, nephropathy, and retinopathy (together termed triopathy). This study determines the prevalence of diabetic complications (retinopathy, nephropathy, and peripheral neuropathy) in diabetic patients with symptoms of Gp, assessing the differences between T1DM and T2DM and delayed and normal gastric emptying (GE).

METHODS:

Diabetic patients with symptoms of Gp underwent history and physical examination, GE scintigraphy, electrogastrography with water load, autonomic function testing, and questionnaires assessing symptoms and peripheral neuropathy.

RESULTS:

One hundred thirty-three diabetic patients with symptoms of Gp were studied: 59 with T1DM and 74 with T2DM and 103 with delayed GE and 30 without delayed GE. The presence of retinopathy (37% vs 24%; P = 0.13), nephropathy (19% vs 11%; P = 0.22), and peripheral neuropathy (53% vs 39%; P = 0.16) was not significantly higher in T1DM than in T2DM; however, triopathies (all 3 complications together) were seen in 10% of T1DM and 3% of T2DM (P = 0.04). Diabetic patients with delayed GE had increased prevalence of retinopathy (36% vs 10%; P = 0.006) and number of diabetic complications (1.0 vs 0.5; P = 0.009); however, 39% of diabetic patients with delayed GE did not have any diabetic complications.

DISCUSSION:

In diabetic patients with symptoms of Gp, delayed GE was associated with the presence of retinopathy and the total number of diabetic complications. Only 10% of patients with T1DM and 3% of those with T2DM had triopathy of complications, and 39% of diabetic patients with Gp did not have any diabetic complications. Thus, the presence of diabetic complications should raise awareness for Gp in either T1DM or T2DM; however, diabetic Gp frequently occurs without other diabetic complications.
Eutanasia: los factores sociales del deseo de morir
Authors: Torre Díaz Javier de la
Published: October 2019

La petición de eutanasia y el deseo de morir, en muchas ocasiones, tiene causas sociales. Lo primero en una sociedad es afrontar esas condiciones sociales antes que facilitar la muerte. Muchas personas no quieren morir sino vivir de otro modo. El artículo analiza veinte factores que condicionan ese deseo de morir: soledad, aislamiento, desconfianza, falta de participación y sentido de comunidad, abandono, depresión, falta de cuidados paliativos, falta de afecto, temor a ser una carga económica, la presión de los familiares, el cansancio, la falta de respeto a la vida frágil y vulnerable, la dificultad de manejar el sufrimiento, el incremento del poder médico, etc. Las sociedades y los países deben luchar por transformar estas condiciones sociales para posibilitar una mejor atención para estas personas y luchar, más allá de la eutanasia, por evitar sufrimientos causados por problemas de tipo social.
Algunas consideraciones para una valoración desde la teología moral al debate sobre la eutanasia en Colombia
Authors: Roldán García Santiago
Published: October 2019

La existencia de importantes posiciones epistemológicas se demuestra en el debate sobre la eutanasia en Colombia. No solo se discute el carácter sagrado de la vida en general, sino también el reconocimiento ético y moral de las pautas sociales, culturales, legales e incluso religiosas. En atención a lo anterior, no podemos seguir contribuyendo a una polarización nacional innecesaria de pensamientos, acciones y omisiones que tienden al desprecio de los principios constitucionales de igualdad, respeto y solidaridad diseñados sin ninguna pretensión absolutista o ningún deseo de agrupación física, mental, emocional, ética o moral.
Left Ventricular Assist Device as Destination Therapy
Authors: Guglin Maya , Miller Leslie W.
Published: October 2019

Mechanical circulatory support is the most rapidly evolving strategy in heart failure management. The growing number of patients who need better results than medical therapy can offer, the limited pool of donors for cardiac transplantation, and several technological breakthroughs have all made the option of implanting a left ventricular assist device (LVAD) as destination therapy more important.

In this review, we outline the indications and decision making process of considering a patient for a destination therapy LVAD, as well as outcomes, complications, and issues related to management of patients on currently approved devices. The future direction of the field will be determined by progress in technology and by further improvement in size, durability, pump dynamics, and most importantly, by solving the problem of supplying energy to the pump without a percutaneous driveline.
Inotropes Are Not Linked to Increased Mortality in Heart Failure
Authors: Guglin Maya
Published: October 2019

How to use inotropes is one of the most controversial topics in the management of heart failure. While most clinicians use these drugs, and recognize the state of inotrope dependency, current guidelines recommend them onlu as a bridge or palliation. Thus, inotropes are considered either neutral or detrimental in terms of outcomes. Meanwhile, properly designed randomized clinical trials testing the outcomes on inotropes, have never been performed and it is unlikely that they will ever be attempted. These trials would require randomizing patients with advanced heart failure, low output syndrome, and impaired end-organ perfusion into groups that received or not received inotropes, or received inotropes or placebo. Many physicians would consider this design unethical so the trials would be challenging to implement. But if it is unethical to deny inotropes to this subset of patients, we have to admit that inotropes do not only improve quality of life, but prolong it, or decrease mortality. Otherwise, we consider it unethical to deny the medication which increases mortality. In this review, we analyze the current evidence relating to inotropes and outcomes. We demonstrate that the original trials were performed with agents that are no longer in use, or on patients without an indication for inotropes, or at a time before automatic cardio-defibrillators were recommended for primary prevention. We conclude that current guidelines for inotropes are misleading in their interpretation of outcomes in patients with advanced heart failure. The guidelines should be revised to adequately reflect the evidence.
Inotropes Are Linked to Increased Mortality in Heart Failure
Authors: Alraies M Chadi , Tran Bill , Adatya Sirtaz
Published: October 2019

With the advancement of technology and availability of mechanical circulatory support (MCS) devices for the treatment of acute decompensated systolic HF in the 21st century, the role of inotropes is becoming obsolete. Medical therapy for acute decompensated heart failure (HF) has not changed since 1960’s, we still use supplemental oxygen, diuretics, vasodilators and inotropes to improve congestion, cardiac output, end organ perfusion and symptoms related to elevate filling pressures1 . Despite demonstrated improvements in hemodynamics, the uses of inotropes have not demonstrated any improvements in mortality. Mechanical circulatory support (MCS) use is growing rapidly in the USA, in patients with stage D HF both as destination therapy and as a bridge to cardiac transplantation. In both, transplant-eligible and non-transplant-eligible patients, improvement in end-organ perfusion, functional capacity, quality of life and most importantly mortality have been demonstrated. In this perspective paper we are going to discuss the current lack of evidence for inotropic therapy and the evolving benefit of MCS in end-stage systolic HF patients.
Renal Replacement Therapy in Patients with Left Ventricular Assist Device: What do the Cardiologists Need to Know?
Authors: Omar Hesham R.
Published: October 2019

Renal failure after left ventricular assist device (LVAD) implantation occurs either due to worsening chronic kidney disease which is common in end-stage heart failure, or due to acute kidney injury in the peri-implantation period, and is associated with high morbidity and short-term mortality. The increased utilization of LVAD in refractory heart failure either as a bridge to transplantation or destination therapy will eventually create a population of patients with LVADs who are dialysis-dependent. There are multiple challenges encountered during dialysis of patients with LVADs including the unfamiliarity of nephrologists with the LVAD technology, difficulty in hemodynamic monitoring with continuous flow devices, risk of access site infection or bleeding and poor arteriovenous fistula maturation and these reasons are the source for the reluctance of outpatient dialysis centers to accept such cases. The nephrologists as well as cardiologists should be familiar with these obstacles to avoid adverse consequences to these high risk patients. Herein, we explore the challenges encountered during dialysis of patients with LVADs.
Old School Still Has Merit: ECG as a Marker of Cardiac Recovery at Weaning from Mechanical Circulatory Support
Authors: Goldraich Livia Adams , Rao Vivek , Billia Fillio , Ross Heather Joan
Published: October 2019

In a case of acute cardiac allograft failure requiring temporary mechanical circulatory support (MCS), serial electrocardiograms (ECG) denoted the degree of myocardial inflammation and damage caused by severe rejection and subsequent recovery. This case highlights the relevance of the ECG during temporary MCS and suggests that resolution of acute electrocardiographic abnormalities might be a marker of myocardial recovery to help guide appropriate timing for weaning from MCS in the setting of acute graft failure.
Chronic Hemodialysis in a Patient with Left Ventricular Assist Device
Authors: Idris Amr , Lolay Georges , Castellanos Ana L. , Rajagopalan Navin , Guglin Maya
Published: October 2019

Renal dysfunction in the setting of heart failure is a common medical problem. This dysfunction can range from reversible ischemic changes to renal failure requiring renal replacement therapy. Patients who are candidates for mechanical circulatory support with left ventricular assistant device (LVAD) pose unique challenge with respect to receiving dialysis. We present a 47 year old patient who required renal replacement therapy peri-implantation of LVAD for management of acute on chronic kidney disease, and was discharged for chronic hemodialysis in an outpatient setting. In this report we highlight the challenges of managing volume overload in patients with impaired renal function refractory to optimal medical therapy as well as the possibility of implanting LVADs in patients on hemodialysis.
Chronic LDH Elevation after Left Ventricular Assist Device Implantation
Authors: Omar Hesham R. , Rajagopalan Navin , Guglin Maya
Published: October 2019

A 61-year-old woman who underwent HeartMate II left ventricular assist device placement for non-ischemic cardiomyopathy developed elevated lactate dehydrogenase within two weeks after implantation. After eight months of observation and several hospital admissions during which there was no evidence of pump thrombosis, she presented with clinically manifest hemolysis. During pump exchange there was notable pannus formation on the inflow cannula of the left ventricular assist device. The pannus around the inflow likely existed for several months, limiting the flow and creating a low- grade hemolysis and this low flow state stimulated thrombus formation triggering gross hemolysis. Thoratec analysis of the pump confirmed that the clot was present for about 5 days. Lactate dehydrogenase normalized after pump exchange.
Systemic Candidiasis and Cytomegalovirus Infection in the Setting of Artificial Cardiac Device Deployment
Authors: Thangam Manoj , Akkanti Bindu , Malahafio Maan , Nathan Sriram , Rajapreyar Indranee , Loyalka Pranav , Kar Biswajit , Gregoric Igor D.
Published: October 2019

Heart failure is a serious cause of morbidity and mortality worldwide. The advent of implantable cardiac assist devices has generated a new arsenal for treating severe heart failure. However, the potential ramifications of ventricular assist device (VAD) usage are not fully understood. Immune modulation resulting from VAD implantation is an area of growing research. Although we do not fully understand the mechanisms contributing to host immune alteration, changes in cytokine concentrations, deceased lymphocyte activity, and the local effects of device materials have been shown to down regulate immune function. Infection is a serious complication that affects prognosis in this patient population. Malnutrition, critical status, and cardiovascular stress are additional predisposing factors in this fragile group. Driveline and surgery-associated infections are the most commonly identified culprits. However, decreased host immune function facilitates atypical infections including systemic fungemia and viremia. This case is an interesting example of a VAD associated immune system compromise.
Manifestations of Atrial Tamponade in a Patient Implanted with SynCardia Total Artificial Heart
Authors: Thangam Manoj , Akkanti Bindu , Nathan Sriram , Ocazionez-Trujillo Daniel , Rajapreyar Indranee , Patel Manish K. , Patel Jayesh , Loyalka Pranav , Kar Biswajit , Gregoric Igor D.
Published: October 2019

Implantation rates of the SynCardia Total Artificial Heart (TAH) system is growing owing to the increasing incidence of biventricular heart failure and the limited number of transplantable hearts. Among the complications associated with the device, atrial tamponade is an emergent condition that requires immediate attention. Atrial tamponade occurs when increasing pericardial hemorrhage leads to atrial compression that produces tamponade physiology and compromises cardiac output. Unfortunately to our knowledge, information concerning the early manifestations of tamponade in TAH patients is extremely scarce. Previous reports have focused on decreased cardiac output as an indicator of tamponade. However, other presentations including pulmonary decompensation are largely undescribed. This case provides a valuable account of the early manifestations of atrial tamponade observed prior to diminished cardiac output.
The Bubbling Aorta
Authors: Omar Hesham R. , Guglin Maya
Published: October 2019

We are presenting the image of the bubbles in the descending aorta in a patient on VA ECMO.
Commentary on "Systemic candidiasis and cytomegalovirus infection in the setting of artificial cardiac device deployment"
Authors: Huaman Moises A.
Published: October 2019

Thangam and associates [1] report the case of an unfortunate elderly male with history of coronary artery disease who developed an acute myocardial infarction due to occlusion of the right coronary artery. This was complicated by the development of a ventricular septal defect and refractory heart failure requiring implantation of cardiac devices including intra-aortic balloon pump, ventricular assist device (VAD) and ultimately total artificial heart (TAH). Despite all efforts, the patient expired ~3 months after the AMI event.
Pulmonary Congestion (White Lungs) on VA ECMO
Authors: Guglin Maya , Burchett Andrew , Tribble Thomas , Charnigo Richard
Published: October 2019

Background

Veno-arterial extracorporeal membrane oxygenation therapy (VA ECMO) is used for short-term circulatory support in the setting of cardiogenic shock or cardiac arrest. While VA-ECMO improves hemodynamics and gas exchange, it may result in left ventricular distention and pulmonary congestion.

Methods

The records of all patients supported with VA ECMO for at least three consecutive days at our institution from 2012-2014 were retrospectively analyzed. All chest radiographs taken during VA ECMO support were graded on a scale of 1 to 4. A score of 1 was used when no pulmonary congestion was present. A score of 2 was used for congestion occupying less than half of both lungs. A score of 3 was used for diffuse congestion occupying over half of both lung fields. A score of 4 was used when complete opacification of both lungs was present. Grades 3 and 4 were considered “white lungs”. The presence of white lungs was examined as a categorical variable. The grade of congestion was examined as a continuous variable. Ordinal logistic regression was used for the analysis.

Results

The sample size analyzed included 46 events of VA ECMO support in 44 individual patients. In 34 (73.9%) patients the lungs became opacified and reached a score of 3 or 4 (the white lungs group), while in 12 (%) patients there were no white lungs. Overall, the percentage of patients that survived to weaning off VA ECMO was 60.9%. The percentage of patients that survived to hospital discharge was 37.0%. In patients who did not have white lungs the percentages of survival to weaning off VA ECMO and survival to hospital discharge were 91.7% and 66.7%, respectively. In those with white lungs, the percentages of survival to weaning off VA ECMO and survival to hospital discharge were 50.0% and 26.5%, respectively (p=0.019 for discharged alive). The duration of VA ECMO support, ECMO flow, daily fluid balance, sum net fluid balance for the length of stay, and use of hemodialysis predicted a higher degree of pulmonary congestion.

Conclusion

Severe pulmonary congestion, or white lungs, is common in patients on VA ECMO and is associated with very poor prognosis. Longer duration of support, greater positive fluid balance, higher ECMO flow, and use of hemodialysis are linked to development of white lungs.
Exploring Body Mass Index Changes in Left Ventricular Assist Device Patients
Authors: Thomas Raquel E. , Hanson Corrine , Woscyna Glenda , Lowes Brian D.
Published: October 2019

Background: Current treatment options for end-stage heart failure, such as transplantation, can be limited by obesity guidelines. Mechanical devices such as Left Ventricular Assistive Devices (LVAD) can bridge heart failure patients to transplantation, however, after implantation; some patients may experience weight gain that precludes them from transplantation. Therefore, the objective of this study was to evaluate weight changes after the implantation of an LVAD.

Methods: A retrospective review of 130 patients receiving an LVAD were divided into two groups based on BMI at the time of implantation: obese (>30 kg/m2) and non-obese (/m2). Patients were evaluated at three time points post LVAD implantation: 3, 6, and 12 months for changes in weight and BMI.

Results: The mean BMI of the overall cohort at the time of LVAD implantation was 30.3 kg/m2. Patients who were not classified as obese at the time of LVAD implementation had a significant increase in BMI (2.1 kg/m2, p<0.001).

Conclusion: Weight gain after LVAD implementation is more likely in patients who are non-obese at the time of LVAD evaluation; however, obese subjects remained unlikely to lose weight one year post implantation.
Caregiver Burden is Low Nine to Twelve Months after Ventricular Assist Device Implantation
Authors: Ghashghaei Roxana , Tran Hao , Silva Jorge , Greenberg Barry H. , Barnard Denise , Adler Eric
Published: October 2019

Background

Prior studies have found that caregivers of chronically ill patients, including those with heart failure, have significant stress and burden. Ventricular Assist Devices (VADs) are a promising therapeutic modality for end stage heart failure. However, caregiver burden has not previously been studied in the caregivers of VAD patients.

Methods

We studied 31 caregivers of VAD patients receiving care at University of California, San Diego. Validated instruments tools, such as the Bakas Caregiving Outcomes scale and Oberst Caregiving Demand and Difficulty sub-scales, were used to measure the caregivers’ psychological burden.

Results

Nearly half of the caregivers were the patient’s spouse or partner (55%) with a mean age of 57 years. When evaluating caregiver burden difficulty, 23/31 (74.2%) of the caregivers experienced little to no difficulty, 5/31 (16.1%) had mild difficulty, and 3/31 (9.6%) noted moderate difficulty. When assessing caregiver burden demand, 17/31 (54.8%) experienced little to no demand, 8/31 (25.8%) reported mild to moderate, 5/31 (16.1%) noted moderate to severe, and 1/31 (3.2%) had severe demand. Using the Baka’s scale, 27/31 (87.1%) reported that VADs were not disruptive to their lives.

Conclusions

In this single center study, we found that 80-90% of VAD caregivers had little caregiver burden difficulty or demand, which is significantly less than published studies of caregivers of patients with other chronic diseases. Further study will be required to validate these findings and compare them to other therapies for end stage heart failure, such as cardiac transplantation.
Favorable Outcomes of LVAD as Bridge to Simultaneous Heart-Kidney Transplantation
Authors: Thohan Vinay , Murtaza Ghulam , Encarnacion Carlos O. Encarnacion , Sulemanjee Nasir , Cheema Omar , Hastings Thomas , Cho Chi , Downey Frank
Published: October 2019

Background

Chronic kidney disease (CKD) is an established risk factor for incident cardiovascular disease and progression of heart failure disease state, and is associated with decreased survival after left ventricular assist device (LVAD) therapy or heart transplantation (HT). Combined heart-kidney transplantation (HKT) compared with isolated HT recently has been shown to have survival advantage among patients whose estimated glomerular filtration rate is less than 37 ml/min/m2. Data on LVAD to HKT are limited.

Methods

At our center, a total of 803 patients have received HT, 594 patients LVAD therapy, and 23 patients HKT from single donors; of those 23, 15 were without the use of LVAD and 8 were after support with LVAD.

Results

Kaplan-Meier survival analysis found LVAD-supported patients with CKD stages 4 or 5 had statistically worse 24-month survival after HT as compared with those with CKD stage 1, 2, and 3 (58% versus 88%, p=0.01). Patients who received combined HKT after LVAD had comparable 24-month survival with those who received HKT without LVAD (87% and 85%, p=NS); both groups had numerically better survival compared with those who had CKD (stage 4-5) with isolated HT (58%).

Conclusions

Patients supported with LVAD who demonstrate advanced CKD (stage 4-5) have worse 24-month post-HT survival compared with those with less advanced CKD (stage 1-3). Combined HKT after LVAD support is feasible and confers comparable 24-month survival compared with HKT without prior LVAD therapy. Our study supports combined HKT for select LVAD patients with advanced CKD (stage 4-5).
VA-ECMO in Cardiogenic Shock in Adults: Indications and Outcomes
Authors: Guglin Maya , Burchett Andrew
Published: October 2019

Background

Use of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) has become increasingly common as a means of providing hemodynamic support for patients in cardiogenic shock. Data regarding the efficacy of VA-ECMO are provided almost exclusively by single-center, retrospective analyses. These retrospective analyses vary significantly with regards to documentation of the underlying pathophysiologic process resulting in cardiogenic shock.

Methods

Relevant published studies were identified by using a comprehensive search of English-language MEDLINE from 1966 to November 2015. Relevant references found cited in these studies were also analyzed. These studies were analyzed with regard to the indications the authors used for initiation of ECMO, as well as the outcomes for each indication in each individual study.

Results

Analysis of multiple relevant studies regarding the indications for ECMO support demonstrated that there is a great deal of variability with regard to the use of different indications for initiation of ECMO support.

Conclusions

Data regarding the efficacy of VA-ECMO is derived largely from single-center, retrospective analyses. In order to gain a better understanding of the efficacy of VA-ECMO in different patient populations, a more standardized format of documenting the indication for VA-ECMO should be used in centers that provide VA-ECMO. In general, all patients supported with VA-ECMO are in cardiogenic shock. In our experience, the underlying processes leading to cardiogenic shock can be classified as: cardiac arrest, acute decompensated congestive heart failure, acute on chronic congestive heart failure, myocardial infarction, acute pulmonary embolism, right ventricular failure not secondary to acute pulmonary embolism, and post-cardiotomy syndrome.
Fulminant Necrotizing Eosinophilic Myocarditis: A Case Report and Comprehensive Literature Review
Authors: George Bennet , Hager Matthew , Cornea Virgilius , O'Connor William , Guglin Maya
Published: October 2019

Acute eosinophilic myocarditis is a relatively rare disorder with serious morbidity and mortality. Due to its infrequency, standardized management guidelines are wanting. We present a case of acute, necrotizing eosinophilic myocarditis requiring several levels of critical care. We reviewed similar cases reported in the literature to highlight common clinical features, describe natural disease course and associated complications, and review varying approaches to medical therapy.
Orthotopic heart transplant following implantation of a systemic ventricular assist device in a patient with congenitally corrected transposition of the great arteries and dextrocardia situs inversus totalis
Authors: Young Bree Ann C. , Nealy Zachariah B. , McGrath Michael F. , Herre John M.
Published: October 2019

Congenitally corrected transposition of the great arteries (CCTGA) is a rare congenital heart disease that commonly results in congestive heart failure due to exposure of the anatomic right ventricle to systemic pressures. Additional anatomic abnormalities, such as situs inversus, in which the viscera are mirror images of normal anatomy, or dextrocardia in which the heart apex is located on the patient’s right, once were contraindications to transplant in the treatment of advanced heart failure. However, recent advancements now allow for the management of heart failure through mechanical circulatory support and subsequent transplant. This case presents a 52 year-old man with advanced heart failure secondary to CCTGA and dextrocardia situs inversalis totalis that was managed with a ventricular assist device (VAD) after maximal medical treatment, and subsequently received an orthotopic heart transplant. This case will also review CCTGA in relation to heart failure and the surgical challenges faced in terms of ventricular assist device implantation and orthotopic heart transplant.
The Utility of Remote Hemodynamic Monitoring Devices in Patients with a Ventricular Assist Device
Authors: George Bennet , Hart Amanda , Branam Sarah , Guglin Maya
Published: October 2019

Remote intracardiac hemodynamic monitoring is a growing area of interest to help aid in the management of patients with chronic congestive heart failure. The utility of remote hemodynamic monitoring has not previously been investigated with a ventricular assist device population. We present two cases of patients with ventricular assist devices in which we employed remote hemodynamic monitoring data to aid in patient management.
Ligation of the Outflow Graft of the Left Ventricular Assist Device for Management of Hemolysis Due to Pump Thrombosis
Authors: Touchan Jean , Shafii Alexis , Guglin Maya
Published: October 2019

Pump thrombosis is a serious complication of continuous-flow left ventricular assist devices (LVAD). Treatment options include medical thrombolysis, surgical pump exchange or urgent heart transplantation. We are reporting a case of pump thrombosis with active hemolysis and acute renal failure managed surgically by isolating the LVAD while awaiting renal recovery and donor heart availability.
Safety and Efficacy of Routine Bridging Anticoagulation for Subtherapeutic Anticoagulation in Outpatients with a Left Ventricular Assist Device
Authors: Shisler David C. , Vaidya Gaurang N. , Muncy Lori , Vijayakrishnan Rajakrishnan , Slaughter Mark S. , Birks Emma J. , Abramov Dmitry
Published: October 2019

Background

Anticoagulation with vitamin K antagonists is vital to prevent pump thrombosis in patients with left ventricular assist devices (LVADs). However, the safety and efficacy of bridging anticoagulation for the routine management of subtherapeutic international normalized ratio (INR) in stable outpatients remains poorly characterized.

Methods 

In this retrospective study, a total of 60 LVAD outpatients had 110 episodes of subtherapeutic INR noted on routine testing. 34 of these episodes were managed with parenteral bridging anticoagulation and 76 were managed with only an adjusted dose of warfarin. The rates of bleeding and thromboembolic adverse events following these episodes of subtherapeutic INR were measured to evaluate the safety and efficacy of bridging anticoagulation in this population.

Results

Ischemic cerebrovascular events occurred following 2 bridged episodes compared to 4 non-bridged episodes (6% vs. 5%, p=0.895). Hemolysis occurred following 1 bridged episode compared to 3 non-bridged episodes (3% vs. 4%, p=0.794). Bleeding events occurred after 4 bridged episodes compared to 13 non-bridged episodes (12% vs. 17%, p=0.474). In a subgroup of patients with either a CHA2DS2-VASc score > 3 or a history of atrial fibrillation, thromboembolic events occurred only in those who did not receive bridging anticoagulation although this result was not statistically significant.

Conclusions

There was no benefit associated with the routine use of bridging anticoagulation in a general population of stable LVAD outpatients with subtherapeutic INR. A trend towards benefit was seen in a subset of patients with a CHA2DS2-VASc score of > 3 or a history of atrial fibrillation.
De-airing method of an axial flow left ventricular assist device influences post-operative lactate dehydrogenase levels: a possible explanation for some episodes of pump thrombosis
Authors: Tanaka Daizo , Rizvi Syed-Saif Abbas , Boyle Andrew , Entwistle John WC
Published: October 2019

Background

Pump thrombosis (PT) is a relatively uncommon but serious complication of a left ventricular assist device (LVAD). We believe that de-airing of the HeartMate II (HMII) with the pump turned on and a clamp across the outflow graft may lead to early thrombus formation due to heat generation on the bearings.

Methods

Patients who underwent HMII implantation from November 2012 to February 2016 were retrospectively reviewed. Patients were separated into two groups depending on the timing of removing the clamp from the outflow graft. Patients in Group 1 underwent de-airing by turning on the pump with the vascular clamp on the outflow graft and patients in Group 2 were completely de-aired with the pump off and the pump was only activated after removing the clamp.

Results

There were 45 patients in Group 1 (“clamp on”) and 33 patients in Group 2 (“clamp off”). Five patients had PT in Group 1 but none in Group 2 (p=0.07). Average LDH levels in the early postoperative period were similar (404±168 IU/L vs 425±267 IU/L; p=0.71). However, average LDH levels in the late postoperative period were significantly higher in Group 1 (388±214 IU/L vs 313±73 IU/L; p=0.045).

Conclusion

De-airing a running HMII with the outflow graft clamped increases LDH levels, suggesting that the bearings may act as a nidus for early thrombus formation caused by the lack of heat dissipation. Delaying pump activation until removal of the clamp on the outflow graft may affect the incidence of PT after HMII implantation. This may have potential importance in any VAD where there are mechanical bearings or other areas susceptible to heat generation.
Unresponsive Patient with LVAD: A Case Series
Authors: Musa Ameer Z. , Akhtarekhavari Julia
Published: October 2019

Mechanical circulatory support (MCS) for patients with advanced heart failure (HF) is becoming more commonplace as technology has progressed and reliability of these systems has improved. We report our experience with three patients with cardiopulmonary arrest in the hospital and propose a protocol for the prompt assessment and treatment of an unresponsive patient with a LVAD in place. We presented three cases of unresponsive patients on LVAD support with low flow or no flow through the LVAD. Although all three of them were alive after resuscitation, none survived to discharge. In all three cases, there were no flaws in LVAD per se, with power source and controller appropriately attached, and the pump functioning normally. The low flow state was secondary to non-cardiac conditions (respiratory acidosis, dehydration, and stroke). In early 2017 we developed our algorithm for unresponsive LVAD patients. Utilization of LVAD flow, which can be obtained quickly and non-invasively at the bedside of a patient is used to direct resuscitation efforts in this proposed protocol. Rapid and standardized protocol for resuscitation of LVAD patients with in-hospital cardiopulmonary arrest is necessary to decrease morbidity and mortality. Further investigation regarding the best practice in this clinical scenario is evolving and further studies are needed.
Reversal of fixed pulmonary hypertension with transcatheter valve replacement for aortic insufficiency on ventricular assist device support
Authors: Ahmad Faraz S. , Ricciardi Mark J. , Davidson Laura J. , Anderson Allen S. , Ghafourian Kambiz , Okwuosa Ike , Vorovich Esther , Wilcox Jane E. , Holloway Daniel D. , Pham Duc T. , Rich Jonathan D.
Published: October 2019

We present a 43-year-old woman with a nonischemic cardiomyopathy implanted with a ventricular assist device (VAD) as bridge to transplant due to severe, “fixed” pulmonary hypertension (PH). Within three months of VAD implant, her “fixed” PH had resolved entirely. Nearly two years later, still supported with a VAD because of severe HLA allosensitization, she developed dyspnea and “moderate” aortic insufficiency (AI) by standard criteria. Invasive hemodynamics revealed recurrence of severe PH in the setting of elevated left-sided filling pressures. We concluded the AI was indeed severe and the cause of her symptoms and recurrent PH. Despite her noncalcified aortic valve and small body habitus, after a thorough assessment, including meticulous annular measurements and appropriate valve sizing, she underwent a transcatheter aortic valve replacement (TAVR) with complete resolution of both her AI and recurrent, severe PH. This case highlights, in a single patient, reversal of “fixed” PH with adequate left ventricular unloading, that “moderate” AI by standard criteria is often “severe” and must be considered in a VAD patient with recurrent PH, and the need for meticulous pre-procedural planning for TAVR in patients with VADs, including accurate measurements of the aortic annulus to ensure adequate oversizing of the valve.
A Modified Access Technique of Impella 5.0 Axillary Artery Insertion
Authors: Alameddine Abdallah K , Binnall Brian , DiBiasio-White Eric , Alameddine Khaled O
Published: October 2019

The conventional method for the axillary artery insertion of Impella 5.0 is a nontunneling route of the side-graft. We present an alternative technique in order to facilitate device insertion and to ensure protection from potential wound contamination. The technique consists of exiting the graft separately and away from the main incision with an intact skin and subcutaneous fat between the two sites. By proper isolation of the main wound, the risk of infection can thus be largely mitigated. Furthermore, this technique allows a better landing entry angle of graft insertion; the resulting smoother curve trajectory leads to facile device insertion, while the risk of kinking after resumption of flow is readily avoided. A further possible advantage would be a less likely to produce thrombosis at the anastomosis. Differences of this technique have already been reported for insertions of extracorporeal membrane oxygenation (ECMO), and for aortic dissections and aneurysms. Our experience in 8 cases suggests the applicability of our method to access the axillary artery for Impella 5.0 insertion.
Restoration Of Left Ventricular Function Following LVAD Implantation – Remission Or Recovery? A Case series
Authors: Joshi Shiksha , Barlow Mariah , Guglin Maya
Published: October 2019

Background

A wide range of left ventricular (LV) recovery rates on left ventricular assist device (LVAD) support have been reported. In this case series, we summarize our experience with LVAD explantation for presumed LV recovery.

Case series

Out of 240 patients who received an LVAD implant in our program since its inception, we explanted/inactivated the pump for presumed LV recovery in only three patients. All three of these patients had relapse of cardiomyopathy within 6 months of explantation.

Conclusion

Our experience does not support the existence of LV recovery following LVAD implantation as a common phenomenon. Improvement in LV function on LVAD is sustainable only with mechanical circulatory support and once the offloading support provided by the device is removed recurrent failure quickly ensue. Likely the term “remission” reflects the status more accurately than the term “recovery”.
Implanted Hemodynamic Monitoring in Management of Significant Right Heart Failure before and after Left Ventricular Assist Device Implantation: Creation and Maintenance of Fontan Physiology in Severe Right Ventricular Dysfunction
Authors: Yei Kevin , Kaisi Casey , Mohan Rajeev , Srivastava Ajay , Heywood J Thomas
Published: October 2019

In the left ventricular assist device (LVAD) population, right ventricular (RV) failure represents a significant cause of morbidity and mortality. It is unclear whether hemodynamic monitoring with the implantable CardioMEMS system can improve outcomes within this population. This case report highlights two patients in our clinic who had CardioMEMS implanted after LVAD, enabling us to modify their medical regimens remotely and more frequently in the management of their RV failure.