Faculty Bibliography

BACKGROUND:Late graft failure (LGF) is an unresolved issue after orthotopic heart transplant (OHT). In this study, we report characteristics and outcomes of severe LGF requiring mechanical circulatory support (MCS). METHODS:All patients undergoing OHT from 2000 to 2018 at our center were reviewed. Patients re-admitted to the hospital for late graft failure (>3 months after initial discharge) and developing cardiogenic shock requiring MCS were identified. Outcomes and mortality were evaluated. RESULTS:Twenty-six patients were identified. Median age was 37.3 years (interquartile range: 28.2-47.6) and 69% were male. Median time from initial transplant to MCS was 2.9 years. Etiology of graft failure was rejection in 19 patients (73%), transplant coronary artery disease (tCAD) in 3 (12%), with mixed tCAD or rejection in 4 (15%).

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45-72) with a median ECLS duration of 2.2 days (IQR 0.6-5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30-50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22-8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14-0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.

BACKGROUND:COVID-19 has spread worldwide and has caused significant morbidity and mortality. Myocardial injury and thrombo-embolism are known complications for those with severe forms of disease. The incidence and risk factors for these complications for those patients who are asymptomatic or with mild forms of COVID-19 is unknown. CASE SUMMARY/METHODS:In this report we describe the case of a 35-year-old man with no past cardiac history who presented with chest pain and a high-sensitivity troponin level of 386 ng/L in the context of an unspecified mild viral illness 1 month previously. Diagnostic evaluation revealed a new cardiomyopathy, left ventricular thrombus, and mid right coronary artery thrombosis. The coronary thrombosis was treated with thrombectomy. SARS-CoV-2 antibodies returned positive. He initially did well post-procedure; however, prior to discharge, he developed a second arterial thrombo-embolism event, a middle cerebral artery stroke. He was treated with thrombectomy and remains hospitalized. DISCUSSION/CONCLUSIONS:Recognition that mild COVID-19 can be complicated by subsequent cardiac injury and/or coagulopathy is important. As more people recover from this viral illness and return to normal activity levels, discussion among cardiac experts has begun regarding screening for occult myocardial injury in those who plan to resume competitive athletic activity. This case highlights the need for investigation regarding (i) the duration of thrombophilia after recovery from illness; (ii) the population that should receive thromboprophylaxis; and (iii) the duration of thromboprophylaxis therapy for COVID-19.

Critical care cardiology has been impacted by the coronavirus disease-2019 (COVID-19) pandemic. COVID-19 causes severe acute respiratory distress syndrome, acute kidney injury, as well as several cardiovascular complications including myocarditis, venous thromboembolic disease, cardiogenic shock, and cardiac arrest. The cardiac intensive care unit is rapidly evolving as the need for critical care beds increases. Herein, we describe the changes to the cardiac intensive care unit and the evolving role of critical care cardiologists and other clinicians in the care of these complex patients affected by the COVID-19 pandemic. These include practical recommendations regarding structural and organizational changes to facilitate care of patients with COVID-19; staffing and personnel changes; and health and safety of personnel. We draw upon our own experiences at NewYork-Presbyterian Columbia University Irving Medical Center to offer insights into the unique challenges facing critical care clinicians and provide recommendations of how to address these challenges during this unprecedented time.

The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to >187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, and myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a Heart-Lung team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.

Novel coronavirus-19 disease (COVID-19) is an escalating, highly infectious global pandemic that is quickly overwhelming healthcare systems. This has implications on standard cardiac care for ST-elevation myocardial infarctions (STEMIs). In the setting of anticipated resource scarcity in the future, we are forced to reconsider fibrinolytic therapy in our management algorithms. We encourage clinicians to maintain a high level of suspicion for STEMI mimics, such as myopericarditis which is a known, not infrequent, complication of COVID-19 disease. Herein, we present a pathway developed by a multidisciplinary panel of stakeholders at NewYork-Presbyterian/Columbia University Irving Medical Center for the management of STEMI in suspected or confirmed COVID-19 patients.

Coronavirus disease 2019 (COVID-19) is a global pandemic affecting 185 countries and >3 000 000 patients worldwide as of April 28, 2020. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, which invades cells through the angiotensin-converting enzyme 2 receptor. Among patients with COVID-19, there is a high prevalence of cardiovascular disease, and >7% of patients experience myocardial injury from the infection (22% of critically ill patients). Although angiotensin-converting enzyme 2 serves as the portal for infection, the role of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers requires further investigation. COVID-19 poses a challenge for heart transplantation, affecting donor selection, immunosuppression, and posttransplant management. There are a number of promising therapies under active investigation to treat and prevent COVID-19.