Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions

Clinically, it is highly challenging to promote recovery in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Despite recent advances in understanding the underlying mechanisms of ALF and ACLF, standard medical therapy remains the primary therapeutic approach. Liver transplantation (LT) is considered the last option, and in several cases, it is the only intervention that can be lifesaving. Unfortunately, this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant. Another option is to restore impaired liver function with artificial extracorporeal blood purification systems. The first such systems were developed at the end of the 20^th century, providing solutions as bridging therapy, either for liver recovery or LT. They enhance the elimination of metabolites and substances that accumulate due to compromised liver function. In addition, they aid in clearance of molecules released during acute liver decompensation, which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy, multiple-organ failure, and other complications of liver failure. As compared to renal replacement therapies, we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems. Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging. The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins. Furthermore, conventional methods such as plasma exchange are being re-evaluated, and novel adsorption filters are increasingly being used for liver indications. These strategies are very promising for the treatment of liver failure. Nevertheless, the best method, system, or device has not been developed yet, and its probability of getting developed in the near future is also low. Furthermore, little is known about the effects of liver support systems on the overall and transplant-free survival of these patients, and further investigation using randomized controlled trials and meta-analyses is needed. This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy. It focuses on general principles of their function, and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF. In addition, we have outlined the basic advantages and disadvantages of each system.

COVID-19 and the heart

An outbreak of coronavirus disease 2019 (COVID-19) occurred in December 2019 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is a strain of SARS-CoV. Patients infected with the virus present a wide spectrum of manifestations ranging from mild flu-like symptoms, cough, fever and fatigue to severe lung injury, appearing as bilateral interstitial pneumonia or acute respiratory failure. Although SARS-CoV-2 infection predominantly offends the respiratory system, it has been associated with several cardiovascular complications as well. For example, patients with COVID-19 may either develop type 2 myocardial infarction due to myocardial oxygen demand and supply imbalance or acute coronary syndrome resulting from excessive inflammatory response to the primary infection. The incidence of COVID-19 related myocarditis is estimated to be accountable for an average of 7% of all COVID-19 related fatal cases, whereas heart failure (HF) may develop due to infiltration of the heart by inflammatory cells, destructive action of pro-inflammatory cytokines, micro-thrombosis and new onset or aggravated endothelial and respiratory failure. Lastly, SARS-CoV-2 can engender arrhythmias through direct myocardial damage causing acute myocarditis or through HF decompensation or secondary, through respiratory failure or severe respiratory distress syndrome. In this comprehensive review we summarize the COVID-19 related cardiovascular complications (acute coronary syndromes, myocarditis, HF, arrhythmias) and discuss the main underlying pathophysiological mechanisms.

Coexisting Morbidity Burden in Hospitalized Elderly Patients with New-Onset Heart Failure vs Acutely Decompensated Chronic Heart Failure

Coexisting morbidities (CM) are common in patients with heart failure (HF). This study evaluated the CM burden and its clinical significance in elderly hospitalized patients with new-onset (De-novo) HF (n = 84) and acutely decompensated chronic HF (ADCHF) (n = 122). All had HF symptoms associated with: (a) LVEF <50%, or, (b) left ventricular ejection fraction (LVEF) ≥50% and NT-proBNP ≥300 pg/mL. The primary endpoint was the composite of all-cause death/HF rehospitalization at 6 months. Age was similar between patients with new-onset HF and ADCHF [82 (12.5) vs 80 (11) years, respectively; P = .549]. The CM burden was high in both groups. However, the number of CM [3 (2) vs 4 (1.75)] and the prevalence of multimorbidity [CM ≥2; 65 (77.4%) vs 108 (88.5%)] were lower in new-onset HF ( P = .016 and P = .035, respectively). The survival probability without the primary endpoint was higher in new-onset HF than in ADCHF ( P = .001) driven by less rehospitalizations ( P = .001). In the total study population significant primary endpoint predictors were red blood cell distribution width (RDW), urea, and coronary artery disease (CAD) prevalence (AUC of the model =.7685), whereas significant death predictors were RDW, urea, and the number of CM (AUC = .7859), all higher in ADCHF. Thus, the higher CM burden in ADCHF than in new-onset HF most likely contributed to the worse outcome.

Patent hemostasis of radial artery: Comparison of two methods

BACKGROUND

Radial artery obstruction is the most common complication of coronary angiography performed via transradial access. Patent hemostasis can significantly reduce the risk of radial artery occlusion. Previous studies utilized sophisticated methods to evaluate radial artery patency. Simplified and easily applicable methods for successful patent hemostasis are currently lacking.

AIM

To determine which method (pulse oximeter vs the traditional radial artery palpation) is better to achieve patent hemostasis.

METHODS

This prospective, single center study included 299 consecutive patients who underwent coronary angiography or percutaneous coronary intervention between November 2017 and July 2019. Patients less than 18 years old, with a history of radial artery disease, or no palpable artery pulse were excluded from the study. Patients were randomly assigned to two groups. In the first group, radial artery flow was assessed by palpation of the artery during hemostasis (traditional method). In the second group, radial artery patency was estimated with the use of a pulse oximeter. Two different compression devices were used for hemostasis (air chamber and pressure valve). The primary study endpoint was the achievement of successful patent hemostasis.

RESULTS

The two groups (pulse oximeter vs artery palpation) had no significant differences in age, sex, body mass index, risk factors, or comorbidities except for supraventricular arrhythmias. The percentage of patients with successful patent hemostasis was significantly higher in the pulse oximeter group (82.2% vs 68.1%, P = 0.005). A lower percentage of patients with spasm was recorded in the pulse oximeter group (9.9% vs 19.0%, P = 0.024). The incidence of local complications, edema, bleeding, hematoma, vagotonia, or pain did not differ between the two groups. In the multivariate analysis, the use of a pulse oximeter (OR: 2.35, 95%CI: 1.34-4.13, P = 0.003) and advanced age (OR: 1.04, 95%CI: 1.01-1.07, P = 0.006), were independently associated with an increased probability of successful patent hemostasis. The type of hemostatic device did not affect patent hemostasis (P = 0.450).

CONCLUSION

Patent hemostasis with the use of pulse oximeter is a simple, efficient, and safe method that is worthy of further investigation. Larger randomized studies are required to consider its clinical implications.

Red blood cell distribution width in elderly hospitalized patients with cardiovascular disease

BACKGROUND

Red blood cell distribution width (RDW) is elevated in patients with cardiovascular disease (CVD).

AIM

To determine RDW values and impact of CV and non-CV coexisting morbidities in elderly patients hospitalized with chronic CVD.

METHODS

This prospective study included 204 consecutive elderly patients (age 77.5 [7.41] years, female 94 [46%], left ventricular ejection fraction 53.00% [37.50, 55.00]) hospitalized with chronic CVD at the Cardiology Department of Larissa University General Hospital (Larissa, Greece) from January 2019 to April 2019. Elderly patients were selected due to the high prevalence of coexisting morbidities in this patient population. Hospitalized patients with acute CVD (acute coronary syndromes, new-onset heart failure [HF], and acute pericarditis/myocarditis), primary isolated valvular heart disease, sepsis, and those with a history of blood transfusions or cancer were excluded. The evaluation of the patients within 24 h from admission included clinical examination, laboratory blood tests, and echocardiography.

RESULTS

The most common cardiac morbidities were hypertension and coronary artery disease, with acutely decompensated chronic heart failure (ADCHF) and atrial fibrillation (AF) also frequently being present. The most common non-cardiac morbidities were anemia and chronic kidney disease followed by diabetes mellitus, chronic obstructive pulmonary disease, and sleep apnea. RDW was significantly elevated 15.48 (2.15); 121 (59.3%) of patients had RDW > 14.5% which represents the upper limit of normal in our institution. Factors associated with RDW in stepwise regression analysis were ADCHF (coefficient: 1.406; 95% confidence interval [CI]: 0.830-1.981; P < 0.001), AF (1.192; 0.673 to 1.711; P < 0.001), and anemia (0.806; 0.256 to 1.355; P = 0.004). ADCHF was the most significant factor associated with RDW. RDW was on average 1.41 higher for patients with than without ADCHF, 1.19 higher for patients with than without AF, and 0.81 higher for patients with than without anemia. When patients were grouped based on the presence or absence of anemia, ADCHF and AF, heart rate was not increased in those with anemia but was significantly increased in those with ADCHF or AF.

CONCLUSION

RDW was elevated in elderly hospitalized patients with chronic CVD. Factors associated with RDW were anemia and CV factors associated with elevated heart rate (ADCHF, AF), suggesting sympathetic overactivity.

Gastroenterology and liver disease during COVID-19 and in anticipation of post-COVID-19 era: Current practice and future directions

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a major threat to global public health. The virus causes the clinical syndrome known as coronavirus disease 2019 (COVID-19), in which multiple organs can get affected. Apart from manifestations of the respiratory system, which predominate, its clinical presentation is frequently accompanied by symptoms of the gastro-intestinal (GI) tract and liver abnormalities. The correlation of symptoms and abnormalities with disease severity is discussed, leading to ambiguous results from international literature. Moreover, the disease infects patients with co-existing liver and GI disorders affecting both their health status and the availability of healthcare services provided to them. The risk of transmission of the disease during aerosol-generating procedures has changed the diagnostic approach and follow-up algorithms for liver and GI diseases. For the safety of both doctors and patients, telemedicine and distant evaluation have become everyday practice, whereas several routines and emergency visits at outpatient and emergency departments have been postponed or delayed. Vaccination against SARS-CoV-2 is underway, providing hope to humanity and the expectation that the post-COVID-19 era is near. This review aims to update knowledge about the manifestations of COVID-19 related to liver and GI diseases and the effect of the pandemic on the diagnostic and therapeutic procedures for these diseases with a special focus on how current practices have changed and what changes will possibly remain in the future.

Inadvertent direct pulmonary artery catheterization complicating the effort for subclavian venous cannulation and central venous catheter placement: A case report and review of the literature

Subclavian access is commonly used in the intensive care unit (ICU) for central venous catheterization. Many complications have been reported during the placement of central venous catheters including pneumothorax, hemothorax, hematoma, and bleeding. The direct, through the thoracic wall, catheterization of pulmonary artery is a very rare one with only three previous reports in the literature. We report a patient who was catheterized for subclavian venous catheter placement, but the imaging techniques (chest X-ray and computed tomography with reconstruction of the images) revealed the direct positioning of the catheter into the pulmonary trunk, fortunately without other adverse events for the patient. Our case report in accordance with recent review of the literature strongly emphasizes the benefits of performing ultrasound-guided interventions in ICU.

Relative contribution of risk factors/co-morbidities to heart failure pathogenesis: interaction with ejection fraction

Aims

The relative impact of each individual coexisting morbidity on the pathogenesis of heart failure (HF) is incompletely understood. This study aimed to evaluate the prevalence of individual cardiac and non‐cardiac coexisting morbidities both in the overall HF population and in the subgroup of HF patients with a single coexisting morbidity, stratified by left ventricular ejection fraction (LVEF) categories, as a measure of the relative contribution of each co‐morbidity to the pathogenesis of HF.

Methods and results

This is a prospective, observational study, in which unselected ambulatory patients with chronic HF visiting the HF clinic of a tertiary university hospital from January 2016 to January 2019 were classified according to baseline LVEF into three groups: (i) LVEF < 40%, (ii) LVEF = 40–49%, and (iii) LVEF ≥ 50% and then evaluated for various coexisting morbidities. Overall, 1064 patients (age 73.4 ± 12.1 years, male gender 57.7%, LVEF 43.6 ± 13.9, N‐terminal pro‐brain natriuretic peptide 2187 ± 710 ng/L, and estimated glomerular filtration rate 67.2 ± 25 mL/min/1.73 m²) were recruited in this study. Of these, 361 (33.9%) had an LVEF < 40%, 247 (23.2%) an LVEF = 40–49%, and 456 (42.9%) an LVEF ≥ 50%. There were 90 (8.5%) HF patients with a single coexisting morbidity, 33 (36.7%) with LVEF ≥ 50%, 27 (30.0%) with LVEF = 40–49%, and 30 (33.3%) with LVEF < 40%. Among these patients, those with LVEF ≥ 50% suffered mostly from hypertension (85.7%), whereas the second most common coexisting morbidity was atrial fibrillation (AF) (9.5%). HF patients with LVEF = 40–49% usually suffered from hypertension (35.7%), AF (28.6%), or myocardial infarction (MI) (21.4%). Finally, HF patients with LVEF < 40% usually suffered from MI (30.8%), AF (30.8%), or hypertension (15.4%).

Conclusions

Hypertension is strongly associated with the development of HF with low, intermediate, or near‐normal/normal LVEF whereas a history of MI or AF with HF with a low or an intermediate LVEF.

Coexisting Morbidities in Heart Failure: No Robust Interaction with the Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

Heart failure (HF) patients often present with multiple coexisting morbidities. In this review, we contend that coexisting morbidities are highly prevalent and clinically important regardless of the left ventricular ejection fraction (LVEF).

RECENT FINDINGS

Multimorbidity is prevalent in the ambulatory subjects of the community and increases with age. Differences in the prevalence of coexisting morbidities between HF with preserved LVEF (> 50%), mid-range LVEF (40-50%), and reduced LVEF (< 40%) are either not demonstrable or whenever present are small and unrelated to morbidity and mortality. The constellation of coexisting morbidities together with the disease modifiers (age, sex, genes, other) defines the HF phenotype and outcome. There is no robust evidence supporting an interaction in HF patients between the prevalence and clinical significance of coexisting morbidities and the LVEF.

Combination of thrombolytic and immunosuppressive therapy for coronavirus disease 2019: A case report

In a proportion of patients, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a multisystem syndrome characterized by hyperinflammation, acute respiratory distress syndrome (ARDS), and hypercoagulability. A 68-year-old man with coronavirus disease 2019 (COVID-19) was admitted to the intensive care unit with respiratory failure, cytokine release syndrome (CRS), and skin ischemia - microthrombosis. Specific coagulation and inflammatory markers (D-dimer, ferritin, and C-reactive protein), along with the clinical picture, triggered the trial of recombinant tissue plasminogen activator (rt-PA) and tocilizumab. This was followed by resolution of the skin ischemia and CRS, while respiratory parameters improved. No major complications associated with rt-PA or tocilizumab occurred. The combination of rt-PA with targeted anti-inflammatory treatment could be a new therapeutic option for patients with COVID-19, ARDS, hyperinflammation, and increased blood viscosity.

Sudden Arrhythmic Death at the Higher End of the Heart Failure Spectrum

The risk of sudden cardiac death (SCD) is high in heart failure (HF) patients. Sudden arrhythmic death (SAD) is a frequent cause of exit in HF patients at the lower end of the HF spectrum, and implantable cardioverter–defibrillators have been recommended to prevent these life-threatening rhythm disturbances in select patients. However, less is known regarding the cause of SCD in patients at the upper end of the HF spectrum, despite the fact that the majority of out-of-hospital SCD victims have unknown or near-normal/normal left ventricular ejection fraction (LVEF). In this review, we report the epidemiology, summarize the mechanisms, discuss the diagnostic challenges, and propose a stepwise approach for the prevention of SAD in HF with near-normal/normal LVEF.

Predictors of Need for Critical Care Support, Adverse Events, and Outcome after Stroke Thrombolysis

BACKGROUND

Results from trials and international registries exhibit heterogeneity regarding safety, efficacy, markers of prognosis, and markers of the need for critical care support after intravenous thrombolysis (IVT) for strokes. The purpose of our study was to indentify such markers after performance of comparisons among patients who received thrombolysis in our intensive care unit.

MATERIALS AND METHODS

Our study included 124 patients who received IVT in accordance with international criteria. Outcome measures of univariate and regression analyses resulted from comparisons between groups of patients with or without the need for critical care support (advanced life support and neurocritical care interventions), groups of patients developing or not developing primary adverse events (symptomatic intracranial hemorrhage [SICH] and/or Death and/or Serious systemic bleeding and/or New stroke) and groups of patients with different main outcome variables (mortality, functional independence at 3 months).

RESULTS

Our results suggested that higher severity scores (Simplified Acute Physiology Score II, National Institutes of Health Stroke Scale) correlated with the need for critical care support, primary adverse events, and main outcome variables, whereas older age was significantly associated with fewer adverse events. Hyperlipidemia, symptom-to-needle time, and vascular disease were associated with functional capacity at 3 months, whereas diabetes mellitus and vascular disease correlated with the need for critical care support.

CONCLUSION

Patients' age, hyperlipidemia, presence of vascular disease, Simplified Acute Physiology Score II (a novel marker), and National Institutes of Health Stroke Scale at 2 hours and at 7 days are independent predictors of the need for critical care support, adverse events, and clinical outcomes after thrombolysis.

Carbamazepine induced atrial tachycardia with complete AV block

BACKGROUND/AIM

Carbamazepine, a widely used antiepileptic drug that has been used for the treatment of both partial and generalized seizures, for trigeminal neuralgia, as a mood stabilizer and for treatment of neuropathic pain syndromes, may have negative chronotropic and dromotropic effects on the cardiac conduction system.

DESCRIPTION OF CASE

We report a case of cardiac syncope due to atrial tachycardia combined with complete atrioventricular block as a consequence of carbamazepine administration for trigeminal neuralgia.

CONCLUSION

Although sinus tachycardia is the most frequently observed cardiac side effect of carbamazepine, sinus and nodal bradycardia, atrioventricular block, premature ventricular contractions, ventricular tachycardia and junctional escape rhythms have been reported in patients due to carbamazepine toxicity.

Salmonella enteritidis Infection Complicated by Acute Myocarditis: A Case Report and Review of the Literature

Salmonella spp. is the cause of commonly encountered infections, with seasonal pattern of occurrence and worldwide distribution. Some of the clinical manifestations such as gastroenteritis and bacteremia are common, whereas others like mycotic aneurysms and osteomyelitis are infrequent especially in immunocompetent patients. Salmonella has been rarely described as a cause of myocarditis in the literature. We describe a case of an 18-year-old previously healthy male patient with myocarditis after Salmonella enteritidis infection. Clinical manifestations and diagnostic approach of this severe complication are discussed with a review of the literature.