Large Left Ventricular Thrombus in a Patient with Systemic and Venous Thromboembolism Secondary to Protein C and S Deficiency

58-year-old Hispanic female presented with an altered mental status. A CT scan of the head demonstrated multiple scattered infarcts and a large right temporal lobe infarct. We also diagnosed the patient with right popliteal and femoral vein thrombosis, bilateral pulmonary embolism, and a transient right radial artery occlusion. Her 12-lead EKG showed lateral ST elevation. Emergent coronary angiogram revealed normal coronaries. Echocardiogram demonstrated a large mobile mass attached to the anterolateral free wall with overall normal contractility of the left ventricle. The patient underwent surgical embolectomy to prevent further systemic embolization. Coagulability workup returned positive for protein C and S deficiency. The patient did well after surgery. Following her surgery, we initiated chronic oral anticoagulation. The presentation with intracardiac thrombus in a normal heart should raise a concern of a probable thrombophilia

CRT-100.04 Delaying Reperfusion Plus LV Unloading Reduces Infarct Size: A Per-Protocol-Analysis of the STEMI_DTU Pilot Study

Background: Myocardial infarct size (IS) and microvascular obstruction (MVO) are well-established prognostic markers in STEMI. The STEMI-DTU pilot trial was the first exploratory study to identify that LV unloading and delayed reperfusion was feasible. We now report new findings in patients from per-protocol cohort on the basis of magnitude of sum of precordial ST-segment elevation. Method: In a multicenter, prospective, randomized safety and feasibility trial, 50 patients with anterior STEMI to LV unloading using Impella CP were assigned into two different arms including immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). Cardiac magnetic resonance (CMR) imaging assessed infarct size normalized to the area at risk (IS/AAR) 3-5 days after PCI. Patients without CMR at 3-5 days, without PCI of a culprit LAD lesion and without STEMI were not per-protocol and thus excluded from this analysis. Results: 32 patients meeting all inclusion and exclusion criteria (U-IR,n=15; U-DR,n=17) were included in our analysis. Despite longer symptom-to-balloon times in the U-DR arm, IS/AAR was significantly lower with 30 minutes of delay to reperfusion in the presence of active LV unloading (47±16% vs 60±15%, p=0.02) and remained lower irrespective of the magnitude of precordial ΣSTE (Figure 1). MVO was not significantly different between groups (1.5±2.8% vs 3.5±4.8%,p=0.15), but significantly lower in the U-DR arm among patients with precordial ΣSTE≥8mm (1.5±2.5% vs 5.6±5.3%, p=0.04). Conclusion: This analysis supports the paradigm-changing concept that when treated per protocol, 30 minutes of delay to reperfusion with active LV unloading may reduce infarct size irrespective of precordial STE magnitude. Ongoing STEMI-DTU Pivotal trial will provide us further information on these findings

Incidence and clinical outcomes of nosocomial infections in patients presenting with STEMI complicated by cardiogenic shock in the United States

OBJECTIVES: This study addresses the incidence, trends, and impact of nosocomial infections (NI) on the outcomes of patients admitted with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (STEMI-CS) using the United States National Inpatient Sample (NIS) database. METHODS: We analyzed data from 105,184 STEMI-CS patients using the NIS database from the years 2005-2014. NI was defined as infections of more than or equal to three days, comprising of central line-associated bloodstream infection (CLABSI), urinary tract infection (UTI), hospital-acquired pneumonia (HAP), Clostridium difficile infection (CDI), bacteremia, and skin related infections. Outcomes of the impact of NI on STEMI-CS included in-hospital mortality, length of hospital stay (LOS) and costs. Significant associations of NI in patients admitted with STEMI-CS were also identified. RESULTS: Overall, 19.1% (20,137) of patients admitted with STEMI-CS developed NI. Trends of NI have decreased from 2005-2014. The most common NI were UTI (9.2%), followed by HAP (6.8%), CLABSI (1.5%), bacteremia (1.5%), skin related infections (1.5%), and CDI (1.3%). The strongest association of developing a NI was increasing LOS (7-9 days; OR: 1.99; 95% CI: 1.75-2.26; \u3e9 days; OR: 4.51; 95% CI: 4.04-5.04 compared to 4-6 days as reference). Increased mortality risk among patients with NI was significant, especially those with sepsis-associated NI compared to those without sepsis (OR: 2.95; 95% CI: 2.72-3.20). Patients with NI were found to be associated with significantly longer LOS and higher costs, irrespective of percutaneous mechanical circulatory support placement. CONCLUSIONS: NI were common among patients with STEMI-CS. Those who developed NI were at a greater risk of in-hospital mortality, increased LOS and costs

Large Left Ventricular Thrombus in a Patient with Systemic and Venous Thromboembolism Secondary to Protein C and S Deficiency

58-year-old Hispanic female presented with an altered mental status. A CT scan of the head demonstrated multiple scattered infarcts and a large right temporal lobe infarct. We also diagnosed the patient with right popliteal and femoral vein thrombosis, bilateral pulmonary embolism, and a transient right radial artery occlusion. Her 12-lead EKG showed lateral ST elevation. Emergent coronary angiogram revealed normal coronaries. Echocardiogram demonstrated a large mobile mass attached to the anterolateral free wall with overall normal contractility of the left ventricle. The patient underwent surgical embolectomy to prevent further systemic embolization. Coagulability workup returned positive for protein C and S deficiency. The patient did well after surgery. Following her surgery, we initiated chronic oral anticoagulation. The presentation with intracardiac thrombus in a normal heart should raise a concern of a probable thrombophilia

Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect

BACKGROUND: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown. METHODS AND RESULTS: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS. CONCLUSIONS: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD

Delaying Reperfusion Plus LV Unloading Reduces Infarct Size: A Per-Protocol-Analysis of the STEMI_DTU Pilot Study

Background: Myocardial infarct size (IS) and microvascular obstruction (MVO) are well-established prognostic markers in STEMI. The STEMI-DTU pilot trial was the first exploratory study to identify that LV unloading and delayed reperfusion was feasible. We now report new findings in patients from per-protocol cohort on the basis of magnitude of sum of precordial ST-segment elevation. Method: In a multicenter, prospective, randomized safety and feasibility trial, 50 patients with anterior STEMI to LV unloading using Impella CP were assigned into two different arms including immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). Cardiac magnetic resonance (CMR) imaging assessed infarct size normalized to the area at risk (IS/AAR) 3-5 days after PCI. Patients without CMR at 3-5 days, without PCI of a culprit LAD lesion and without STEMI were not per-protocol and thus excluded from this analysis. Results: 32 patients meeting all inclusion and exclusion criteria (U-IR,n=15; U-DR,n=17) were included in our analysis. Despite longer symptom-to-balloon times in the U-DR arm, IS/AAR was significantly lower with 30 minutes of delay to reperfusion in the presence of active LV unloading (47±16% vs 60±15%, p=0.02) and remained lower irrespective of the magnitude of precordial ΣSTE (Figure 1). MVO was not significantly different between groups (1.5±2.8% vs 3.5±4.8%,p=0.15), but significantly lower in the U-DR arm among patients with precordial ΣSTE\u3e8mm (1.5±2.5% vs 5.6±5.3%, p=0.04). Conclusion: This analysis supports the paradigm-changing concept that when treated per protocol, 30 minutes of delay to reperfusion with active LV unloading may reduce infarct size irrespective of precordial STE magnitude. Ongoing STEMI-DTU Pivotal trial will provide us further information on these findings. [Formula presented

Red cell Distribution Width and Risk of Cardiovascular Mortality: Insights from National Health and Nutrition Examination Survey (NHANES)-III.

INTRODUCTION: Red cell distribution width (RDW) has been linked to cardiovascular disease. We sought to determine whether addition of RDW improved the Framingham risk score (FRS) model to predict cardiovascular mortality in a healthy US cohort. METHODS: We performed a post-hoc analysis of the National Health and Nutritional Examination Survey-III (1988-94) cohort, including non-anemic subjects aged 30-79years. Primary endpoint was death from coronary heart disease (CHD). We divided the cohort into three risk categories:20%. RDW\u3e14.5 was considered high. Kaplan-Meier survival curves and Cox proportional hazards models were created. Discrimination, calibration and reclassification were used to assess the value of addition of RDW to the FRS model. RESULTS: We included 7005 subjects with a mean follow up of 14.1years. Overall, there were 233 (3.3%) CHD deaths; 27 (8.2%) in subjects with RDW\u3e14.5 compared to 206 (3.1%) in subjects with RDW≤14.5 (p CONCLUSIONS: Our study demonstrates that RDW is a promising biomarker which improves prediction of cardiovascular mortality over and above traditional cardiovascular risk factors