The adverse prognostic implications of significant renal dysfunction during treatment of acute decompensated heart failure (HF) in patients with obese HF and preserved ejection fraction (HFpEF) ...provide strong rationale for development of therapeutic strategies that enhance decongestion while preserving renal function in this cohort. The combination of preload sensitivity, intrinsic renal dysfunction related to obesity, glomerular hyperfiltration, reversible renal hypoperfusion (poor renal arterial perfusion and renal venous congestion), and decreased systemic vascular resistance in obesity may predispose patients to renal hemodynamic compromise during diuresis. Thus, serum creatinine increase should not be evaluated in isolation but rather considered in the context of the entire clinical picture in patients with obese HFpEF.
Heart failure (HF) with preserved ejection fraction (HFpEF) is the most rapidly increasing form of HF, occurs primarily in older women, and is associated with high rates of morbidity, mortality, and ...health care expenditures. In the highest age decile (≥90 years old), nearly all patients with HFpEF. As our understanding of the disease has grown in the last few years, we now know that HFpEF is a systemic disorder influenced by aging processes. The involvement of this broad collection of abnormalities in HFpEF, the recognition of the high frequency and impact of noncardiac comorbidities, and systemic, multiorgan involvement, and its nearly exclusive existence in older persons, has led to the recognition of HFpEF as a true geriatric syndrome. Most of the conventional therapeutics used in other cardiac diseases have failed to improve HFpEF patient outcomes significantly. Several recent studies have evaluated exercise training (ET) as a therapeutic management strategy in patients with HFpEF. Although these studies were not designed to address clinical endpoints, such as HF hospitalizations and mortality, they have shown that ET is a safe and effective intervention to improve peak oxygen consumption, physical function, and quality of life in clinically stable HF patients. Recently, a progressive, multidomain physical rehabilitation study among older adults showed that it is feasible in older patients with acute decompensated HF who have high frailty and comorbidities and showed improvement in physical function. However, the lack of Centers for Medicare and Medicaid Services coverage can be a major barrier to formal cardiac rehabilitation in older HFpEF patients. Unfortunately, insistence upon demonstration of mortality improvement before approving reimbursement overlooks the valuable and demonstrated benefits of physical function and life quality.
Background The stiff left atrial syndrome (SLAS), a possible complication of catheter ablations or MAZE procedures for atrial fibrillation, results in increased left atrial scar formation resulting ...in left atrial hypertension. Case A 71 years old man with HFpEF and chronic atrial fibrillation, who had undergone multiple catheter ablations for atrial arrhythmias, presented to hospital for a 3rd time in 6 months for heart failure exacerbation.
Heart transplantation is the treatment of choice for many patients with end-stage heart failure (HF). However, organ donor supply is limited. Ventricular assist devices (VAD) are increasingly used ...for the management of HF as a bridge to transplantation (BTT) or destination therapy (DT). Some patients with VADs have partial or full recovery of LV function thus qualifying for explant. Other patients may require an explant/exchange or pump inactivation due to complications of the device. While the infections at drive line site with active LVADs are seen in practice, we present a case of a delayed skin infection at the site of the original drive line.
A 45-year-old man with ischemic cardiomyopathy underwent HeartMate II implant in 2014 as BTT. His subsequent course was complicated by recurrent GI bleeding (GIB). He was admitted in 2016 with GIB and declined further use of Coumadin. He was maintained on ASA but had recurrent bleeding. During these admissions he decided that he was not interested in heart transplantation. He was removed from the UNOS waitlist and his status was switched to VAD as DT. He was readmitted with VAD stoppage, low flows, high powers and chocolate colored urine. LDH>1500 and decreased hemoglobin. He was a poor surgical candidate, declined anticoagulation .He had minimal myocardial recovery with persistent severe LV dysfunction (EF ∼ 10%). He was felt to be too ill to undergo VAD explant surgery. Thus, the VAD was deactivated, inflow cannula and outflow grafts left in situ and the drive line severed and surgically buried. A ∼10-12 cm remnant was buried under the skin (figure). Skin incision was closed primarily. The original exit site was left to heal by secondary intention. The wound completely healed. Luckily, patient continued to do well. Almost a year after VAD inactivation, he developed skin irritation at the site of prior driveline site. He delayed contacting us and presented to clinic with a severe soft tissue infection (Enterobacter cloacae and Staph aureus) at the old driveline site. He required surgical debridement, excision of the driveline, IV antibiotics and a wound-vac. The drive line site is healing well afterwards.
One sees a drive line site infection in VAD patient's, but our case highlights the fact that even if the drive line has been excised and stump buried under the skin, a delayed infection like ours, though unlikely, is still possible.Our case also highlights the fact that leaving all the VAD apparatus in patients who are high risk for explant is a safe option, as our patient continues to do well a year after his VAD deactivation.
A Case Of IVC Stenosis After Heart Transplant Hilton, Thomas; Rasmussen, Bridget; Pisani, Barbara ...
Journal of cardiac failure,
April 2023, 2023-04-00, Letnik:
29, Številka:
4
Journal Article
Recenzirano
Orthotropic Heart Transplant (OHT) is the gold standard treatment for end-stage heart failure patients. One of the complications unique to the bi-caval OHT surgical technique is an increased risk for ...stenosis at the superior vena cava or inferior vena cava (IVC) anastomoses. We hereby present a case of IVC stenosis in immediate post-op period following heart transplant.
A 67-year-old man with ischemic cardiomyopathy underwent a bi-caval OHT per standard surgical protocols. He was noted to have mild right ventricular dysfunction on closing the chest. On return to the ICU, the patient required escalating doses of vasopressors and inotropes. Hemodynamics were notable for mean arterial pressure of 65 mmHg, pulmonary artery pressure of 28/16 mmHg, CVP of 6-7 mmHg, and a cardiac index 2.1%. Serum lactate was 8.78 mmol/L. Patient continued to have progressive hypotension overnight, but remained fluid responsive. CVP continued to remain around 7 mm Hg. Despite multiple pressors and adequate and aggressive fluid resuscitation, patient's serum lactate, AST, and ALT continued to rise throughout the night, peaking at 24.2 mmol/L, 18,257 U/L, and 4,119 U/L, respectively. Progressive abdominal distension was also noted at this time. Abdominal ultrasound revealed a hepatic vein obstruction with no clear etiology. A TEE also showed turbulent flow around the IVC, right at the junction with hepatic veins. This was concerning for some anatomical hindrance to venous return from liver to the IVC. Patient was thus taken back to the OR, where a surgical examination of the IVC revealed narrowing at the previous IVC cannulation site. An IVC patch venoplasty and resection of redundant valve tissue at the IVC atrial anastomosis was thus performed. The patient returned to ICU in stable condition. Luckily after the adequate venous return from IVC was restored, patient's acute liver injury and abdominal distension resolved. Unfortunately, his kidneys did take a major hit, and he required short term dialysis in post-operative period. He is now more than one-year post-transplant, and has shown tremendous renal recovery, not requiring dialysis anymore.
IVC stenosis or obstruction is an uncommon surgical complication associated with the bi-caval anastomosis technique. Though vasoplegia with some degree of RV dysfunction is a common finding in the immediate post-transplant period, and it is treated with inotropic and pressor support along with adequate fluid resuscitation, but these interventions usually result in rapid clearance of lactic acidosis with improvement in end-organ dysfunction within first 12 to 24 hours. Shock refractory to volume resuscitation resulting in liver and renal failure, lactic acidosis, an underfilled left ventricle on TEE, and persistently low intracardiac filling pressures warrant further investigation. Acute IVC occlusion post-transplantation can be challenging to identify due to numerous causes hemodynamic instability and shock state. Liver function abnormalities out of proportion with adequate cardiac indices should prompt further investigation. Careful surgical, hemodynamic and echo visualization and assessment of the anastomotic site are essential.
The utility of therapeutic plasma exchange (TPE) in acute thyrotoxicosis refractory to conventional therapy has been documented in case study literature. TPE has been shown to remove T3 and T4 bound ...to albumin, autoantibodies, catecholamines, and cytokines in patients with thyrotoxicosis. In clinical practice, TPE has been used as a treatment in refractory cases of acute thyrotoxicosis and as a bridge for those patients needing surgical treatment. At present, TPE is listed as an ASFA category III indication for thyrotoxicosis. We present a case of acute thyrotoxicosis and cardiogenic shock responsive to early TPE. A 27-year-old lady presented to our emergency department with dyspnea, nausea, and vomiting. She was found to be in atrial fibrillation with rapid ventricular response, hypotensive, and in acute respiratory distress requiring intubation. Her TSH was undetectable and her clinical condition rapidly declined. She developed acute cardiogenic shock (LVEF < 10%) requiring VA ECMO after she had been on maximal pressor therapy despite conventional treatment for thyroid storm (SSKI, hydrocortisone, PTU, cholestyramine, and esmolol). TPE was initiated with 1:5:1 FFP daily for 3 treatments. Following the initial treatment, her pressor needs were significantly reduced to levophed alone and her T3 and free T4 were markedly reduced. Following all 3 treatments of TPE, pressors were completely weaned off and total T3 had normalized. In the meantime, her left sided filling pressures were still high despite being on ECMO, so an Impella was placed to vent the LV. With corrections of the underlying metabolic /hormonal derangements, her LVEF almost completely recovered, and she was subsequently decannulated from VA ECMO circuit 6 days following completion of TPE. The patient demonstrated remarkable improvement and offers a glimpse into the potential benefit of early identification and treatment of acute thyrotoxicosis and related cardiogenic shock. We advocate a multidisciplinary approach, involving the endocrine, hematology, critical care and cardiology teams for consideration of TPE and MCS in patients with acute thyrotoxicosis with progression to cardiogenic shock refractory to conventional therapy, ideally initiated within 24 hours of diagnosis. A randomized controlled trial for use of early TPE in acute thyrotoxicosis and cardiogenic shock is warranted.
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