Additive Value of Preprocedural Computed Tomography Planning Versus Stand-Alone Transesophageal Echocardiogram Guidance to Left Atrial Appendage Occlusion: Comparison of Real-World Practice

Background: Transesophageal echocardiogram is currently the standard preprocedural imaging for left atrial appendage occlusion. This study aimed to assess the additive value of preprocedural computed tomography (CT) planning versus stand-alone transesophageal echocardiogram imaging guidance to left atrial appendage occlusion. Methods and Results: We retrospectively reviewed 485 Watchman implantations at a single center to compare the outcomes of using additional CT preprocedural planning (n=328, 67.6%) versus stand-alone transesophageal echocardiogram guidance (n=157, 32.4%) for left atrial appendage occlusion. The primary end point was the rate of successful device implantation without major peri-device leak (\u3e5 mm). Secondary end points included major adverse events, total procedural time, delivery sheath and devices used, risk of major peri-device leak and device-related thrombus at follow-up imaging. A single/anterior-curve delivery sheath was used more commonly in those who underwent CT imaging (35.9% versus 18.8%; P\u3c0.001). Additional preprocedural CT planning was associated with a significantly higher successful device implantation rate (98.5% versus 94.9%; P=0.02), a shorter procedural time (median, 45.5 minutes versus 51.0 minutes; P=0.03) and a less frequent change of device size (5.6% versus 12.1%; P=0.01), particularly device upsize (4% versus 9.4%; P=0.02). However, there was no significant difference in the risk of major adverse events (2.1% versus 1.9%; P=0.87). Only 1 significant peri-device leak (0.2%) and 5 device-related thrombi were detected in follow-up (1.2%) with no intergroup difference. Conclusions: Additional preprocedural planning using CT in Watchman implantation was associated with a higher successful device implantation rate, a shorter total procedural time, and a less frequent change of device sizes

Statin-Induced Rhabdomyolysis Complicated by Acute Renal Failure Leading to Dialysis

Learning Objective #1: Recognize life changing consequences of statin induced injury in patients with stage IV CKD Learning Objective #2: Identify statin induced muscle and kidney injury CASE: 56 year old male with presents with generalized malaise, myalgias, tea colored urine and loose stools for 2 days. He denies sick contacts, flu like symptoms, fevers, recent changes in medications, dehydration or recent strenuous exercise. He is a former smoker with 35 pack years, social alcohol consumer and denies illicit drug use. His medications include: aspirin 81mg, atorvastatin 80mg and metoprolol tartrate 25mg for coronary artery disease, amlodipine 10mg for hypertension, lantus 8 units for type 2 diabetes and lasix 60mg for stage IV chronic kidney disease. On examination he was hemody-namically stable, ill appearing obese gentleman with tenderness in the major muscle groups of his upper and lower extremities. The rest of his exam was unremarkable. Laboratory studies revealed hyperkalemia at 6.2 mEq/L, creat-inine 7.70 mg/dL (baseline around 4 mg/dL), calcium 7.8 mg/dL, phosphorus 9.9 mg/dL, his serum ALT was 41 IU/L and AST was 245 IU/L. Urinalysis was significant for hematuria and proteinuria. Creatine protein kinase (CPK) peaked at 452,312. Patient was found to be in rhabdomyolysis leading to acute on chronic renal failure. Statin was removed, patient was started on continuous infusion of normal saline and furosemide drip. CPK was down trending however due to worsening hyperkalemia and hyperphosphatemia despite adequate urine output, a tunneled-cuff catheter was placed and patient was initiated on hemodialysis. Electrolytes and CPK normalized however patients renal function did not improve leading to end stage renal disease. IMPACT/DISCUSSION: Cardiovascular disease is a major cause of morbidity and mortality in the world with the prevalence of cardiovascular diseases doubling by 2020. Statin therapy is the primary pharmacologic therapy to achieve low LDL cholesterol in efforts to improve atherosclerotic cardiovascular disease outcomes in primary and secondary prevention. High doses of statins increase the risk of rhabdomyolysis. The US FDA Adverse Event Reporting System database reports that there are.3-12.5 cases out of 1 million of statin induced rhabdomyolysis. Rhabdomyolysis is syndrome where muscle pain and weakness is caused by muscle tissue breakdown with release of intramuscular contents (enzymes, myoglobin, electrolytes) into the circulation. Myoglobin is cytotoxic to renal tubules and causing tubular cast formation and acute tubular necrosis. Cytokine induced arteriolar vasoconstriction in combination with dehydration Results in decreased glomerular filtration rate and eventually acute renal failure. Conclusion: This case report is aimed to highlight the risks of high dose statin therapy and to consider a medication/dose review in the setting of advanced chronic kidney disease to prolong time to dialysis, ultimately improving quality of life

Penetrating Chest Injury Leading to Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacter-Emia and Mycotic Abdominal Aortic Aneurysm in Immunocompromised Patient

Learning Objective #1: Recognize that mycotic aneurysm is a term used to describe any localized dilation of an artery due to destruction of the vessel wall by infection. This aneurysm can result from the infection or a preexisting aneurysm that becomes infected. Learning Objective #2: Recognize that trauma, endocarditis and impaired immunity are common risk factors for infected aneurysms. CASE: A 52-year-old male with a PMHx of chronic lower back pain s/p laminectomy, presented with a 4 day history of right-sided flank pain, subjective fevers and chills. Additional symptoms included dysuria along with episodic suprapubic pain. Vitals were significant for episodic fever. Physical examination was significant for superficial skin abscesses. He did admit to a recent history of incarceration and reported that he was stabbed in the right upper chest which resulted in a pneumothorax. There was a high index of suspicion for pyelonephritis. UA showed findings consistent with UTI. Initial urine cultures and blood cultures came back positive for MRSA. Due to evidence of persistent bacteremia, IV dapto-mycin and ceftaroline was initiated. CT chest showed findings consistent with septic emboli in the lungs. Echocardiogram was obtained and subsequent transesophageal echocardiogram which were negative for vegetations. MRI was negative for spinal abscess. HIV-1 quantitative and total CD4+ T cell count were obtained and revealed values 102,587 and 11, respectively. At this time, the patient began complaining of acute abdominal pain and painful pulsatile abdominal mass was appreciated on physical exam. CT-abdomen revealed a 3.1x2.8x3.5 cm saccular mycotic aneurysm projecting off the right side of the abdominal aorta. The patient was treated with 6 weeks of daptomycin and placed on dapsone and azithromycin prophylaxis following completion of daptomycin. The patient underwent surgical repair of the aneurysm with a rifampin-soaked Dacron graft and right nephrectomy for an infarcted right kidney. IMPACT/DISCUSSION: This case highlights that pentrating chest injury in a immunocompromised host led to a MRSA bacteremia causing a mycotic aneurysm. The most commonly involved organisms in mycotic aneurysms include S. aureus, Streptococci and Salmonella. In our case, the patient\u27s risk factors for an infected aneurysm were the stab wound which was a likely inoculation site for MRSA and impaired immunity (HIV+). Clinical findings are a painful, pulsatile mass in the abdomen. CT angiog-raphy is the diagnostic test of choice. Empiric antibiotics should include MRSA and gram negative coverage, while definitive treatment is surgical excision of the aneurysm and extensive debridement of infected tissues. Conclusion:-Trauma such as penetrating chest wall injury, endocarditis, and immunocompromised hosts are common risk factors for infected aneurysms-Clinical presentation can include a painful, pulsatile mass-The diagnosis of an infected aneurysm is based upon imaging of the aneurysm and infection is confirmed with blood cultures and/or cultures from aneurysm wall

Aggressive acute coronary thrombosis in ulcerative colitis flare.

Background Thromboembolic disease is a well-recognized complication of Ulcerative Colitis (UC), but coronary involvement is rare. Chest pain in UC flare should raise suspicion for acute coronary thrombosis. Case A 46 year old male with UC was admitted after 3 weeks of bloody diarrhea despite treatment with prednisone. He also reported severe refractory chest pain. ECG showed ST-segment elevation myocardial infarction in inferior/lateral leads. Emergent left heart catheterization (LHC) revealed a large thrombus in mid left anterior descending (LAD) artery with distal embolization. Aspiration thrombectomy was unsuccessful. A drug eluting stent (DES) was placed in mid-LAD. Intracoronary vasodilators improved distal coronary flow. The patient was continued on DAPT. Five days later, his chest pain recurred. Decision-making LHC showed acute in-stent thrombosis. Two DES were placed in overlapping fashion to proximal-mid LAD with PTCA on the diagonal. Persistent thrombus was treated with balloon inflations. The patient continued to be symptomatic, so an intra-aortic balloon bump (IABP) was placed. He was continued on DAPT. Hemodynamics and chest pain improved in next 2 days, and IABP was removed. Conclusion Acute coronary thrombosis in pro-inflammatory states are challenging to treat, since both the underlying condition and treatment of UC are pro-thrombotic. Close monitoring and consideration of mechanical support devices may improve coronary perfusion while controlling the underlying flare

Patients with Biliary Complications Following Orthotopic Liver Transplantation Can Be Successfully Managed by Serial Endoscopic Retrograde Cholangio-Pancreatography

Purpose: We evaluated the quality of endoscopic intervention for biliary complications after liver transplantation in a diverse urban center. Methods: A retrospective chart review of liver transplant recipients from 2015-2018 were included. Exclusion criteria included age \u3e18, pre-transplant biliar-complications including strictures, leaks, primary biliary cirrhosis, primary sclerosing cholangitis, and previous cholecystectomy. Background information included age, race, and donor type (deceased brain death (DBD), deceased cardiac death (DCD), and living donor transplant (LDT)). 1st and 2nd FRCP data included biliary complications. Analysis was performed using chi-square and Fisher\u27s exact tests. Results: 320 patients received a liver transplantation over the course of academic years 2015 (Yl, n=36), 2016 (Y2, n=29), and 2017 (Y3, n=29) respectively. 63. 8% were male, 72. 3% Caucasian, with mean age 57. 4 years (range 23-71). Donors were 7. 4% LDT, 78. 7% DBD, and 13. 8% DCD. FRCP was performed on an average of 1. 97 months from transplant and an average of 2. 96 times per patient. Patients undergoing FRCP for Yl was 35. 6% Y2 23. 2% and Y3 31. 5% of total transplantations (p=0. 111). Initial FRCP showed abnonnal findings in 90. 2% including strictures (76. 1%), biliary sludge (28%), stones (16. 1%) and bile leak (7. 5%). 80% required a follow up FRCP, with 65. 8% having persistence of initial findings requiring repeat treatment. 28. 6% of patients with bile leak who underwent repeat FRCP had persistent leak. Presence of biliary complications did not significantly increase mortality. Death among patients receiving FRCP was 8. 5% versus 8. 0% of those not needing FRCP (p=0. 871). Repeat biliary surgety was needed in 4. 3% (p=0. 054), 42. 9% (p=0. 008), and 20% (p=0. 081) of patients with strictures, bile leak and stones on initial FRCP respectively. Death among patients with stricture, bile leak and biliaty stones was 4/66 (6. 1%), 1/7 (14. 3%), and 0/15 (0%) respectively. There was no statistical difference between Yl, Y2 and Y3 for overall positive find-ings on initial FRCP (p=1. 000), strictures (p=0. 980), bile leak (p=0. 886) or stones (p=1. 000). There was a trend towards increased bile leak among patients with histoty of intraoperative thrombectomy versus those without (20% vs 7. 5%). There were no differences between LDT, DCD and DBD for overall positive findings on initial ERCP(p=0. 814), strictures (p=0. 167), bile leak (p=0. 575) or stones (p=0. 167). Conclusions: Initial FRCP when indicated, had a high likelihood of positive find-ings. Treatment on FRCP was most likely to be needed for patients with a stricture. Biliaty complications did not significantly impact death. FRCP alone was able to resolve the biliary issue in the vast majority of patients with abnormal findings

Inter-hospital transfers in acute myocardial infarction and cardiogenic shock

Background: Limited data exist on the use of “hub and spoke” models to transfer patients who present in cardiogenic shock. We sought to assess outcomes of patients transferred to our shock center within our network to those who presents from institutions out of our network. Methods: From January 2014 to June 2017, 110 patients transferred to our shock center with an admission diagnosis of acute myocardial infarction and cardiogenic shock (AMICS) based on ICD coding. Demographics, admission, procedural and clinical outcomes were obtained for all patients and compared. Statistical analysis was performed using two-sample t-tests, Wilcoxon rank sum tests, chi-square tests and Fisher exact tests. Results: 35 patients were transferred within our network and 75 patients presented out of our network. The average age of the cohort was 66.4 years. In-network patients were less likely to present with in-hospital cardiac arrest (12.1% vs. 35.7%, p=0.013). In-network patients presented with lower cardiac output (CO) (3.2 L/m ± 0.7 vs 4.5 L/m ± 1.0; p=0.019) but were less likely to be on vasopressors (42.3% vs 72.2%, p=0.018) upon transfer. Similarly, in-network patients had a lower cardiac output following initiation of mechanical circulatory support (3.9 L/m ± 0.9 vs. 5.7 L/m ± 2.3, p=0.010), but higher SBP after initiation of MCS (124.7 mmHg ± 28.2 vs. 105.5 mmHg ± 25.2, p=0.006). Overall, in-network patients had shorter delays from AMI onset to MCS when compared to out of network patients. In-network patients had improved survival to hospital discharge (62.9% vs 41.3%, p=0.035). Conclusions: Patients who presented to our shock center from an innetwork hospital had improved survival to hospital discharge when compared to patients who presented from outside our network. Further system based processes are needed to best optimize care of patients transferred with acute myocardial and cardiogenic shock

To bleed or to clot: Stroke prevention strategies in patients with atrial fibrillation or flutter after bleeding

Background Patients with atrial fibrillation or atrial flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding events. A common dilemma is deciding when to safely restart AC after bleeding. Studies have shown better outcomes with reinitiation of AC 7 days after stabilization of gastrointestinal bleeds and 4 weeks after intracranial hemorrhage. Our aim was to assess stroke prevention strategies upon discharge in patients with AF hospitalized with a bleeding event. Methods We retrospectively identified patients with AF on AC who were admitted with a bleeding event. The type of AC, form of bleeding, and CHADS2VASC were collected. Stroke prevention strategies on discharge were noted. Results Between January 2016 and August 2019, 174 patient with AF were hospitalized with a bleeding event. Nearly 10% of patients died, emphasizing the severity of this clinical situation. AC was restarted in 40% of patients upon discharge, 8.6% of patients were referred for LAA closure, and the remaining 40% were discharged without a stroke prevention strategy. CHADS2VASC did not differ among the groups. Of patients discharged on AC, 16% had a repeat bleeding episode requiring hospitalization within 30 days. Conclusion A significant portion of patients with AF hospitalized with a bleed were discharged with no definitive stroke prevention strategy. Barriers to restarting oral anticoagulation should lead to consideration of LAA closure as an alternative