Faculty Bibliography
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69
Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19
BACKGROUND:Thrombosis and inflammation may contribute to morbidity and mortality among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation would improve outcomes in critically ill patients with Covid-19. METHODS:In an open-label, adaptive, multiplatform, randomized clinical trial, critically ill patients with severe Covid-19 were randomly assigned to a pragmatically defined regimen of either therapeutic-dose anticoagulation with heparin or pharmacologic thromboprophylaxis in accordance with local usual care. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. RESULTS:The trial was stopped when the prespecified criterion for futility was met for therapeutic-dose anticoagulation. Data on the primary outcome were available for 1098 patients (534 assigned to therapeutic-dose anticoagulation and 564 assigned to usual-care thromboprophylaxis). The median value for organ support-free days was 1 (interquartile range, -1 to 16) among the patients assigned to therapeutic-dose anticoagulation and was 4 (interquartile range, -1 to 16) among the patients assigned to usual-care thromboprophylaxis (adjusted proportional odds ratio, 0.83; 95% credible interval, 0.67 to 1.03; posterior probability of futility [defined as an odds ratio <1.2], 99.9%). The percentage of patients who survived to hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred in 3.8% of the patients assigned to therapeutic-dose anticoagulation and in 2.3% of those assigned to usual-care pharmacologic thromboprophylaxis. CONCLUSIONS:In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. (REMAP-CAP, ACTIV-4a, and ATTACC ClinicalTrials.gov numbers, NCT02735707, NCT04505774, NCT04359277, and NCT04372589.).
PMCID:8362592
PMID: 34351722
ISSN: 1533-4406
CID: 4980752
Dual-Guide Triple-Kiss Technique for Left Main Trifurcation
PMID: 34052154
ISSN: 1876-7605
CID: 4890682
ST-Segment Elevation Myocardial Infarction in the Morbidly Obese: Use of the "Offloading" Technique
PMID: 33744208
ISSN: 1876-7605
CID: 4822092
Tricuspid valve vegetation debulking using the AngioVac system [Case Report]
Tricuspid valve endocarditis with recurrent septic pulmonary emboli is an indication for surgery. We present the case of a 36-year old man with tricuspid valve endocarditis and septic pulmonary emboli with percutaneous extraction of the vegetation. We discuss the nuances of such an approach and the need for more evidence in the management of these complex patients.
PMID: 33565679
ISSN: 1522-726x
CID: 4779782
Hyperoxia is associated with adverse outcomes in the cardiac intensive care unit: Insights from the Medical Information Mart for Intensive Care (MIMI-III) database [Meeting Abstract]
Background: Hyperoxia produces reactive oxygen species, apoptosis, and vasoconstriction, and is associated with adverse outcomes in patients with heart failure and cardiac arrest. Our aim was to evaluate the association between hyperoxia and mortality in patients (pts) receiving positive pressure ventilation (PPV) in the cardiac intensive care unit (CICU).
Method(s): Patients admitted to our medical center CICU who received any PPV (invasive or non-invasive) from 2001 through 2012 were included. Hyperoxia was defined as time-weighted mean of PaO2 >120mmHg and non-hyperoxia as PaO2 <=120mmHg during CICU admission. Primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and estimated time spent on PEEP.
Result(s): Among 1493 patients, hyperoxia (median PaO2 147mmHg) during the CICU admission was observed in 702 (47.0%) pts. In-hospital mortality was 29.7% in the non-hyperoxia group and 33.9% in the hyperoxia group ((log rank test, p=0.0282, see figure). Using multivariable logistic regression, hyperoxia was independently associated with in-hospital mortality (OR 1.507, 95% CI 1.311-2.001, p=0.00508). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.053 per 10mmHg increase in PaO2, 95% CI 1.024-1.082, p=0.0002).
Conclusion(s): In a large CICU cohort, hyperoxia was associated with increased mortality. Trials of titration of supplemental oxygen across the full spectrum of critically ill cardiac patients are warranted
Method(s): Patients admitted to our medical center CICU who received any PPV (invasive or non-invasive) from 2001 through 2012 were included. Hyperoxia was defined as time-weighted mean of PaO2 >120mmHg and non-hyperoxia as PaO2 <=120mmHg during CICU admission. Primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and estimated time spent on PEEP.
Result(s): Among 1493 patients, hyperoxia (median PaO2 147mmHg) during the CICU admission was observed in 702 (47.0%) pts. In-hospital mortality was 29.7% in the non-hyperoxia group and 33.9% in the hyperoxia group ((log rank test, p=0.0282, see figure). Using multivariable logistic regression, hyperoxia was independently associated with in-hospital mortality (OR 1.507, 95% CI 1.311-2.001, p=0.00508). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.053 per 10mmHg increase in PaO2, 95% CI 1.024-1.082, p=0.0002).
Conclusion(s): In a large CICU cohort, hyperoxia was associated with increased mortality. Trials of titration of supplemental oxygen across the full spectrum of critically ill cardiac patients are warranted
EMBASE:634165460
ISSN: 1522-9645
CID: 4811382
Protected Rotational Atherectomy and DK NanoCrush POT rePOT Technique With Dual Guiding Catheters for Unprotected Distal Left Main
PMID: 33069655
ISSN: 1876-7605
CID: 4641862
ST-Segment Elevation in Patients with Covid-19 - A Case Series [Letter]
PMID: 32302081
ISSN: 1533-4406
CID: 4383882
Effects of Acute Colchicine Administration Prior to Percutaneous Coronary Intervention: COLCHICINE-PCI Randomized Trial
BACKGROUND:Vascular injury and inflammation during percutaneous coronary intervention (PCI) are associated with increased risk of post-PCI adverse outcomes. Colchicine decreases neutrophil recruitment to sites of vascular injury. The anti-inflammatory effects of acute colchicine administration before PCI on subsequent myocardial injury are unknown. METHODS:In a prospective, single-site trial, subjects referred for possible PCI (n=714) were randomized to acute preprocedural oral administration of colchicine 1.8 mg or placebo. RESULTS:=0.001). CONCLUSIONS:Acute preprocedural administration of colchicine attenuated the increase in interleukin-6 and high-sensitivity C-reactive protein concentrations after PCI when compared with placebo but did not lower the risk of PCI-related myocardial injury. Registration: URL: https://www.clinicaltrials.gov; Unique Identifiers: NCT02594111, NCT01709981.
PMID: 32295417
ISSN: 1941-7632
CID: 4383552
ASSOCIATION BETWEEN POSITIVE END-EXPIRATORY PRESSURE, FILLING PRESSURES, AND MORTALITY IN MECHANICALLY VENTILATED PATIENTS WITH PRIMARILY LEFT OR RIGHT VENTRICULAR DYSFUNCTION [Meeting Abstract]
Background Positive end-expiratory pressure (PEEP) may have differential hemodynamic effects according to right ventricular (RV), left ventricular (LV) function and filling pressures. We assessed the association between PEEP and outcomes in patients (pts) admitted to the cardiac intensive care unit (CICU) undergoing mechanical ventilation (MV). Methods Patients undergoing MV in the first 48 hours of CICU admission at Beth Israel Deaconess Medical Center (MIMIC III database) were included. Pts were stratified into preload dependent (hypovolemia, RV dysfunction, tamponade, hypertrophic obstructive cardiomyopathy) and high afterload (LV dysfunction). Pts with a pulmonary artery catheter (PAC) were classified by their pulmonary artery diastolic pressure (PADP) as high (>20mmHg) and normal (<20mmHg). Mortality, lactate clearance and inotropic vasopressor score were compared in pts with PEEP levels above and below the median. Multivariable regression analysis was performed adjusting for age, sex, OASIS score, PaO2, pH, lactate and cardiac arrest on admission. Results We included 321 CICU pts (age 68, IQR 57-78) who had a median PEEP levels of 5.38 (IQR 5.00-6.78) cmH2O in the preload dependent group and 5.00 (IQR 5.00-8.00) cmH2O in the afterload dependent group. Unadjusted hospital mortality was higher in pts receiving PEEP above the median in the preload dependent group (66.7% vs. 36.4%, p=0.04, adjusted OR 1.74 95%CI 0.85-3.57, p=0.12), but not in the afterload dependent group (31.1% vs. 26% p=0.51, adjusted OR 1.002 95%CI 0.81-1.24, p=0.98). In patients with PAC (n=80), multivariate analysis demonstrated no differences in mortality by PEEP in low PADP (OR 0.93, 95%CI 0.38-2.75, p=0.87) or high PADP (OR 1.17, 95%CI 0.72-1.91p=0.51). There were no differences in lactate clearance or inotropic/vasopressor score by PEEP in preload/afterload dependent status and with normal/high PADP. Conclusion In CICU pts undergoing MV, the use of low-moderate levels of PEEP was not associated with differences in outcomes. Further research is warranted to better characterize the impact of PEEP, particularly at higher levels, on hemodynamics and clinical outcomes.
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EMBASE:2005041052
ISSN: 0735-1097
CID: 4367672
Clinical Practice Patterns in Temporary Mechanical Circulatory Support for Shock in the Critical Care Cardiology Trials Network (CCCTN) Registry
BACKGROUND:Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units. METHODS:The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions. RESULTS:Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use. CONCLUSIONS:There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.
PMID: 31707801
ISSN: 1941-3297
CID: 4184762
