Bedside ultrasound of the internal jugular vein to assess fluid status and right ventricular function: The POCUS-JVD study

BACKGROUND

Accurate estimation of fluid status is important in the management of heart failure patients, however, the current methods for bedside assessment can be unreliable or impractical for daily use.

METHODS

Non-ventilated patients were enrolled immediately prior to scheduled right heart catheterization (RHC). Using M-mode, IJV maximum (Dmax) and minimum (Dmin) anteroposterior diameters were measured during normal breathing, while supine. Respiratory variation in diameter (RVD) was calculated as [(Dmax - Dmin)/Dmax] in percentage. Collapsibility with sniff maneuver (COS) was assessed. Lastly, inferior vena cava (IVC) was assessed. Pulmonary artery pulsatility index (PAPi) was calculated. Data was obtained by five investigators.

RESULTS

Total 176 patients were enrolled. Mean BMI was 30.5 kg/m2, LVEF 14-69% (range), 38% with LVEF ≤35%. The POCUS of IJV could be performed in all patients in <5 min. Increasing RAP demonstrated progressive increase in IJV and IVC diameters. For high filling pressure (RAP ≥10 mmHg), an IJV Dmax ≥1.2 cm or IJV-RVD < 30% had specificity >70%. Combining the POCUS of IJV to physical examination improved the combined specificity to 97% for RAP ≥10 mmHg. Conversely, a finding of IJV-COS was 88% specific for normal RAP (<10 mmHg). An IJV-RVD <15% is suggested as a cutoff for RAP ≥15 mmHg. The performance of IJV POCUS was comparable to IVC. For RV function assessment, IJV-RVD < 30% had 76% sensitivity and 73% specificity for PAPi <3, while IJV-COS was 80% specific for PAPi ≥3.

CONCLUSION

POCUS of IJV is an easy to perform, specific and reliable method for volume status estimation in daily practice. An IJV-RVD < 30% is suggested for estimation of RAP ≥10 mmHg and PAPi <3.

Covid-19 positive donor utilization for heart transplantation: The new frontier for donor pool expansion

BACKGROUND

Hearts from COVID-19 positive donors (CPD) are being utilized for heart transplantation by some centers; however, this is in the setting of the lack of guidelines or robust evidence. The paucity of evidence is reflected in the recent Organ Procurement and Transplantation Network (OPTN) communication describing CPD utilization as an "unknown risk."

METHODS AND RESULTS

We analyzed the UNOS database for adult heart transplants performed between January 2021 to December 2022, and CPD comprised of a significant percentage of donors, being used in >10% of recipients in some UNOS regions. Between July 2022 and December 2022, 7.9% of heart transplants were with CPD, and in the same period Hepatitis C positive donors accounted for 7.1% and donation after circulatory death (DCD) accounted for 10.3%.

CONCLUSION

If the transplant community comes up with a standardized approach and guidance in using CPD hearts, this could provide an effective donor pool expansion strategy.

Patterns and outcomes of COVID-19 donor utilization for heart transplant

BACKGROUND

The outcomes following COVID-19 positive donor (CPD) utilization for heart transplant are unknown.

METHODS

UNOS database was analyzed for heart transplants performed from the declaration of COVID-19 pandemic until September 30, 2022.

RESULT

Since the onset of pandemic, there were 9876 heart transplants reported. COVID-19 antigen or NAT results were available in 7698 adult donors within 14 days of donation, of which 177 (2.3%) were positive. There was no difference in recipient demographics, including age (COVID positive donor vs. negative: 55 vs. 56 years, p = .2) and BMI. Listing status 1 and 2 were similar in both groups (7% vs. 10% and 48% vs. 49% respectively, p = .4). Durable and temporary mechanical support were similar in both groups pre-transplant (both groups 33%, p = .9). There was no difference in days on the waitlist (median 31 days, p = .9). Simultaneous renal transplant rates were similar (11% vs. 10%, p = .9). CPD utilization has increased since the onset of the pandemic, and the adoption is present across most UNOS regions. Post-transplant, there was no difference in length of stay (median 16 vs. 17 days, p = .9) and acute rejection episodes prior to discharge (3% vs. 8%, p = .1). In survival analysis of 90-day follow up, number of deaths reported were comparable (5% in both groups, p = .9) Follow-up LVEF was comparable (62% vs. 60%, p = .4).

CONCLUSION

Active COVID-19 infection in donors did not affect survival or rejection rates in the short-term post-heart transplant.

Correlation of internal jugular and subclavian vein diameter variation on bedside ultrasound with invasive right heart catheterization

Introduction

Accurate estimation of fluid status is paramount in patients with heart failure. We hypothesized that bedside ultrasound assessment of the internal jugular vein (IJV) and subclavian vein (SCV) could reliably estimate right atrial pressure (RAP).

Methods

Prospectively enrolled patients were positioned supine. IJV was imaged at the apex of the right sternocleidomastoid muscle and SCV was imaged at the lateral third of the right clavicle. Using M-mode on a portable ultrasound machine, the maximum (D_max) and minimum (D_min) anteroposterior diameters were noted during normal breathing. Respiratory variation in diameter (RVD) was calculated as [(D_max – D_min)/D_max] and expressed as percent. Collapsibility was assessed with sniff maneuver. Patients then underwent right heart catheterization and their findings were correlated with above.

Results

Total of 72 patients were enrolled with mean age 61 years, mean BSA 1.9 m², and left ventricular ejection fraction 45 ± 20%. Elevated RAP≥ 10 mmHg was associated with dilated IJV D_max(1.0 vs. 0.7cm, p = 0.001), less RVD with resting respiration (14% vs. 40% for IJV, p = 0.001 and 24% vs. 45% for SCV, p = 0.001), and reduced likelihood of total collapsibility with sniff (16% vs. 66% patients for IJV, p = 0.001 and 25% vs. 57% patients for SCV, p = 0.01). For RAP ≥10 mmHg, lack of IJV complete collapsibility with sniff had a sensitivity of 84% while IJV D_max > 1cm and RVD <50% had a specificity of 80%.

Conclusion

The IJV and SCV diameters and their respiratory variation are reliable in estimating RA pressure.

Heart Transplantation for Giant Cell Myocarditis: A Case Series

BACKGROUND

Giant cell myocarditis (GCM) has a poor prognosis without heart transplant, but post-transplant survival is unknown.

PURPOSE

To describe the post-transplant survival of patients with GCM at a large transplant center.

METHODS

Seven patients underwent heart transplant for histologically confirmed GCM of the explanted heart. The median age was 59 years, and 43% (3 of 7) were female. All patients had cardiogenic shock, multiorgan failure, elevated troponin, and recurrent ventricular tachycardia, and some required mechanical circulatory support. All patients received rabbit antithymocyte globulin (rATG) in the perioperative period at a dose of 1.5 mg/kg daily for 1 to 5 days and 4 received intravenous immunoglobulin 1 g/kg daily for 2 days after rATG. All patients had early initiation of tacrolimus by first to third postoperative day depending on renal function, early mycophenolate, and high dose steroid. All were maintained using tacrolimus, mycophenolate, and prednisone.

RESULTS

One patient had asymptomatic recurrence of GCM at 3 months, managed by up-titration of tacrolimus, and had asymptomatic 2R cellular rejection at 4 months, managed with steroid bolus. No patient had high-grade rejection. One patient died at 267 days, possibly of GCM. Six of 7 (86%) remain alive at a median of 842 days (2.3 years) post transplant.

CONCLUSIONS

Patients with GCM have excellent post-transplant survival with use of rATG and triple drug immunosuppressive therapy; however, some patients remain at risk for GCM recurrence after transplant, which may respond to augmented immunosuppression.

Simultaneous suction debulking of lead vegetation prior to percutaneous lead extraction

The infection rates of implanted cardiac devices have increased disproportionate to the dramatic increase in implantation rates, possibly related to rising patient comorbidities. Optimum strategy in cases with larger size vegetations, however, remains to be ascertained. In the absence of an effective and less invasive alternative, such patients usually undergo open thoracotomy for lead extraction. We describe the case of a 50-year-old female presenting with recurrent methicillin-resistant Staphylococcus aureus bacteremia found to have 3 cm highly mobile vegetation on the right ventricular lead of her implanted defibrillator. While being intermediate-to-low surgical risk, she underwent AngioVac-directed suction debulking (AngioDynamics, Latham, NY, USA) of the vegetation simultaneously preceding percutaneous laser lead extraction in a single session. This less invasive alternative to open thoracotomy has been described in high surgical risk patients, but its widespread role remains unexplored. <Learning objective: Complete lead extraction is recommended in all cases of lead infection. However in the presence of large-size lead vegetation, the optimum management strategy is still controversial, especially among high-risk surgical patients. AngioVac system (AngioDynamics, Latham, NY, USA) has a centrifugal suction cannula which can offer a safer and less invasive percutaneous alternative to open thoracotomy approach, with a possibility of large-scale application due to faster recovery.>.

Reciprocal ST-Segment Changes in Myocardial Infarction: Ischemia at Distance Versus Mirror Reflection of ST-Elevation

BACKGROUND

Reciprocal ST-depression in the electrocardiograms (ECGs) of patients with ST-elevation myocardial infarction (STEMI) results from either true ischemia at a distance via collateral circulation diverting blood to the infarcted region or an electrical phenomenon that results from a mirror reflection of ST-elevation. We aimed to identify the role of reciprocal ECG changes in predicting collateral circulation to the infarcted area determined angiographically.

METHODS

In a retrospective study, ECG and angiography of 53 STEMI patients admitted to SUNY Upstate Medical University in 2014 were reviewed independently by experts blinded to the results of ECG and coronary angiography.

RESULTS

Reciprocal changes (RC) in ECG were present in 41 patients (77%) and on angiography, 14 patients (26%) exhibited collateral vessels to the ischemic areas. No correlation was found between the presence of RC and collateral circulation (P = 0.384), or between the depth of reciprocal ST-depression and the degree of the collateral circulation (P = 0.195). However, 84% of patients without collaterals exhibited resolution of RC after successful percutaneous coronary intervention (PCI) (P = 0.036), suggesting that the ST depressions that resolved after reperfusion were directly caused by the culprit vessel. Patients without RC presented late after symptom onset (9.25 versus 3.83 hours, P = 0.004), also suggesting time related resolution.

CONCLUSIONS

RC had no relation to or predictive value for collaterals on angiography. Among late presenting patients, RC were less frequent. Thus, reciprocal ST-depression may represent subendocardial ischemia from the primary coronary event or simply an electrical phenomenon, rather than ischemia at distance from impaired collateral circulation.

Application of exercise ECG stress test in the current high cost modern-era healthcare system

Exercise electrocardiogram (ECG) tests boasts of being more widely available, less resource intensive, lower cost and absence of radiation. In the presence of a normal baseline ECG, an exercise ECG test is able to generate a reliable and reproducible result almost comparable to Technitium–99 m sestamibi perfusion imaging. Exercise ECG changes when combined with other clinical parameters obtained during the test has the potential to allow effective redistribution of scarce resources by excluding low risk patients with significant accuracy. As we look towards a future of rising healthcare costs, increased prevalence of cardiovascular disease and the need for proper allocation of limited resources; exercise ECG test offers low cost, vital and reliable disease interpretation.

This article highlights the physiology of the exercise ECG test, patient selection, effective interpretation, describe previously reported scores and their clinical application in today’s clinical practice.

Estimation of Risk Factors for Cardiogenic Shock in Takotsubo Cardiomyopathy: A Retrospective Study

<p>Introduction: Presentation of Takotsubo cardiomyopathy(TCM) widely varies amongst the patients, ranging from asymptomatic patients to cardiogenic shock or even cardiac arrest. The underlying risk factors inherent to the patient that predispose to a catastrophic presentation have not been delineated well in the past.</p><p>Objective: To distinguish risk factors and presenting characteristics of patients diagnosed with cardiogenic shock from TCM.</p><p>Methods: Total 51 angiography-confirmed TCM patients admitted in Upstate Hospital from 2010 – 2014 were compared retrospectively, 13 presenting with cardiogenic shock.</p><p>Results: While TCM was predominantly common in elderly females, four of the total six male TCM patients presented with shock (Odds ratio= 8.0, p=0.027). TSH was higher in cardiogenic shock group. Patients with shock had significantly higher incidence of ST elevations on EKG and higher peak troponins. Moreover, ST elevations were predominantly in the inferior, anteroseptal and lateral leads in the shock group as compared to only the septal leads in the control group. Echocardiography revealed lower LV ejection fraction, LV outflow tract obstruction and concomitant significant mitral regurgitation in shock patients. No correlation was found with age, BMI, coronary disease risk factors (diabetes, hypertension, smoking), coincident infection, electrolyte imbalance, QTc interval length.</p><p>Conclusion: Risk factors and pathophysiology for cardiogenic shock in TCM were identified. TCM in males is rare, but male gender is a risk factor for shock.</p>

Refractory hypoglycaemia in patient with gastric outlet obstruction

A 68-year-old male with a longstanding history of severe gastric outlet obstruction secondary to peptic stricture was found unconscious at home with profound hypoglycaemia. He denied history of fasting, diabetes mellitus or use of hypoglycaemic agents. Systemic examination and metabolic profile were unremarkable. Hypoglycaemic episodes persisted during hospitalisation, requiring continuous intravenous dextrose and eventually diazoxide. Further investigative work up, including 72 h fasting study, revealed a hyperinsulinemic state. MRI and endoscopic ultrasound were unremarkable but mesenteric angiography with hepatic venous sampling revealed a subtle area of hypervascularity in the head of pancreas. An exploratory laparotomy was then performed and resulted in resection of a nodular lesion in the head of pancreas with retrocolic gastrojejunostomy for repair of pyloric stenosis. Histopathology of pancreatic nodule confirmed nesidioblastosis. Postoperatively the patient was weaned of parenteral dextrose and did not have any further episodes of hypoglycaemia.

Gastroparesis as the initial presentation of pulmonary adenocarcinoma

Malignancy-associated gastroparesis is an under-reported entity and its diagnosis as a cause of cachexia or gastrointestinal symptoms is often missed in clinical practice. This case report highlights an unusual association of pulmonary adenocarcinoma with gastroparesis at presentation. Malignancy-associated gastroparesis should be added to the differential diagnosis in patients presenting with delayed gastric emptying of unknown aetiology and should prompt further radiological investigations. Early detection and treatment of underlying gastroparesis in patients with cancer is necessary to improve the quality of life and to avoid premature clinical deterioration due to intolerance to oral treatment.

Enterocolitis without diarrhoea in an adult patient: a clinical dilemma

Campylobacter jejuni is one of the most common causes of bloody diarrhoea in the USA. We report a case of a young woman who presented with a clinical picture reminiscent of acute appendicitis. Ultrasonography and CT of the abdomen performed subsequently revealed evidence of colitis. Quite unexpectedly, she had no symptoms of diarrhoea and the stool Gram stain and culture were negative. Nevertheless, due to high clinical suspicion of infectious colitis, appendectomy was deferred. Blood culture was later reported positive for Campylobacter species and the patient responded to quinolones. With this case report we try to highlight one of the unusual presentations of C jejuni infection, closely mimicking acute appendicitis in the absence of classical symptoms of bacterial enteritis. In such cases, a high index of suspicion, astute history taking skills and the proper use of imaging studies can save the patient from the surgical knife.

Polyarteritis nodosa presenting as profuse gastrointestinal bleeding

A 70-year-old man presented with acute onset of profuse bleeding per rectum. An urgent colonoscopy showed blood throughout the colon and distal ileum but failed to localise the source. Subsequent visceral arteriography revealed pseudoaneurysms of the branches of the superior mesenteric artery and left gastric artery. The bleeding stopped spontaneously and the aetiology of the bleeding was later found out to be secondary to polyarteritis nodosa (PAN). The presence of profuse gastrointestinal bleeding as the sole manifestation at presentation in PAN is under-reported. Early diagnosis of PAN in patients with haemodynamically significant bleeding is necessary as prompt initiation of immunosuppressive therapy helps prevent relapses. With this case report, we highlight one of the unusual presentations of PAN and the favourable response to immunosuppression with pulsed dose steroids.

Complicated rheumatic mitral stenosis presenting in an elderly patient and the challenges in its management

A 76 -year-old lady with a recent diagnosis of rheumatic heart disease (RHD), and a history of repeated lower respiratory tract infections, came with symptoms of gastritis unrelated to the primary disease but further diagnostic study in the hospital revealed poorly controlled atrial fibrillation, grossly dilated left atrium with two large left atrial thrombi and mitral valve area<1 cm(2). It was decided that the best approach in our patient would be mitral valve replacement with mechanical prosthesis. Despite the usual trend of using bioprosthesis in the elderly, our decision was influenced by the fact that the patient would need chronic anticoagulation for atrial fibrillation in any case. The purpose of our case presentation is to illustrate a late-presenting case of RHD with unusual associations and the challenges to choose the best possible management.

Pulmonary infection due to Torulopsis glabrata; report of a case treated with flucytosine

A case of pulmonary infection due to Torulopsis glabrata in a 43-year-old man without other known pulmonary or systemic disease is described. The diagnosis was made from multiple positive sputum cultures. After treatment with flucytosine for 21 months, there was marked symptomatic improvement and radiographic clearing, but sputum cultures continued to yield a few colonies of T glabrata.