POPULARITY
9 episodes with Impella
5 episodes with Impella
6 episodes with Impella
7 episodes with Impella
4 episodes with Impella
3 episodes with Impella
3 episodes with Impella
3 episodes with Impella
2 episodes with Impella
Teaching best practices for transporting Impella patients is something Zac Bunzey handles every day. As a clinical education manager at Life Flight Network, Zac joins Shane Turner to share how targeted training campaigns, hands-on experience, and tools like the Impella app, combined with Abiomed's 24/7 support, have markedly boosted crew confidence and proficiency.Plus, you'll learn about the importance of cognitive aids and routine practice with low-frequency events to maintain skills. Whether you're experienced in Impella transports or new to the process, this episode offers crucial strategies to enhance your crew's readiness and effectiveness in managing these critical patients.In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNZac Bunzey, Clinical Education Manager, Life Flight Network
Are you equipped to handle cardiogenic shock? In this episode, you'll gain insights from an expert on the frontlines about the complexities of caring for these critical patients and how you can excel in providing world-class critical care transport.Shane Turner sits down with Dr. Adam Gottula, an emergency physician and critical care intensivist from Methodist Hospital in San Antonio, Texas. They discuss the management of cardiogenic shock in transport settings, the crucial role of a multidisciplinary approach, and the latest strategies for improving patient outcomes.Dr. Gottula shares the importance of cognitive checklists, standardized patient classification, and the life-saving role of the Impella device during transport. Plus, essential practices for optimizing outcomes in patients with Impella support during cardiac arrest, including the critical steps of prompt CPR and correct device positioning.Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNAdam Gottula, M.D., San Antonio, Texas
In this episode, Dr. Valentin Fuster dives into the complex and high-stakes world of cardiogenic shock, spotlighting new clinical trials, expert consensus guidance, and cutting-edge insights from machine learning. From evaluating the impact of intra-aortic balloon pumps to rethinking mechanical support strategies, the episode delivers a powerful update on one of cardiology's most urgent challenges.
In today's episode of the Legal Nurse Podcast, we delve into the life-saving world of cardiac stents with expert cardiologist Joshua Willis. Discover the evolution of stents, from their inception to their transformative role in treating heart disease. Joshua shares insights into the critical procedures that follow stent insertion and navigates the complexities of balancing patient care with available resources. You'll discover how these medical advancements have changed lives and the collaborative decision-making involved in this vital field. Tune in and explore the fascinating journey of cardiac care! Heart Procedures: Cardiac Stents and Beyond Addresses these Questions: Join us for this episode, during which we discuss these questions. How did the concept of cardiac stents develop, and who was a key figure in their development? What are the differences between bare metal stents and drug-eluting stents, and how do they function in preventing coronary artery blockages? What are the typical medications used post-stent insertion to prevent clot formation, and why are they crucial? How does the radial approach differ from the femoral approach in cardiac procedures, and why has it become more favored? What role does shared governance play in deciding between stent insertion and coronary artery bypass surgery for a patient? Listen to our podcasts or watch them using our app, Expert.edu, available at legalnursebusiness.com/expertedu. Get the free transcripts and also learn about other ways to subscribe. Go to Legal Nurse Podcasts subscribe options by using this short link: http://LNC.tips/subscribepodcast. Are you finding it tough to Grow Your LNC Business? You are not alone! Join us for the 12th LNC SUCCESS® 3-DAY ONLINE CONFERENCE on November 13, 14, & 15, 2025! It's a chance to learn how to overcome common challenges and gain the skills you need to succeed in legal nurse consulting. Connect with industry experts who will share practical strategies for standing out, building strong relationships with attorneys, and effectively presenting your value. No matter your experience level, this conference will empower you to discover fresh opportunities and advance your business. What to Expect Expert-Led Sessions: Engage with sessions led by top industry professionals. Interactive Workshops: Participate in hands-on workshops designed to enhance your consulting skills. Networking Opportunities: Build lasting connections with peers and potential clients. Resource Materials: Receive exclusive materials that will support your ongoing professional development. Don't miss this chance to make a real impact on your business. Register Today Secure your spot at the 12th LNC SUCCESS® 3-DAY ONLINE CONFERENCE on November 13, 14, & 15, 2025, and take your first step toward becoming a leading legal nurse consultant! We look forward to welcoming you to this pivotal event in February 2025! Your Presenter for Heart Procedures: Cardiac Stents and Beyond Joshua M Willis, MD Dr. Willis completed a cardiology fellowship at the Cleveland Clinic Foundation (2007-2010) and an Interventional Cardiology fellowship at the University of Florida (2010-2011). In 2011, he took a private cardiology practice job in Chattanooga, Tennessee, splitting his time between hospital-based procedures (cardiac catheterizations, percutaneous coronary interventions, Swan Ganz catheterization for invasive hemodynamic measurements, Impella device placement etc.) and clinic duties, and seeing approximately 24-26 patients per full clinic day. His job responsibilities at Wellstar include three days in the hospital, providing Interventional and General Cardiology coverage and 1.5 days in clinic seeing outpatients, total of 35-40 outpatient visits per week. Connect with Joshua M Willis, MD by email at cardioexpertwitness@gmail.com,
Today we're going ‘back to basics' with Austin Provence, a cardiothoracic nurse who brings a decade of experience in transporting patients with Impella devices and the importance of seamless teamwork. With over a decade of experience, Austin highlights two critical scenarios: stable patients needing higher care and critically ill patients requiring immediate interventions. He underscores the importance of mastering proper Impella placement and management, noting that a significant portion of these patients may present additional health challenges.Austin shares practical tips on maintaining the correct angle to prevent bleeding, managing sedation, and ensuring clear communication between hospital and transport teams. This episode is packed with best practices and strategies to enhance the competency and confidence of transport clinicians in handling complex cardiac cases.In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNAustin Provence, Hospital Wing Flight Nurse
In this episode, recorded live at the Critical Care Canada Forum in Toronto, we dive into extracorporeal life support (ECLS) in cardiogenic shock, with Dr Sean van Diepen. He is an Associate Professor at the University of Alberta, Co-Director of the CCU at the Mazankowski Alberta Heart Institute, and a leading voice in cardiac critical care. Join us as we explore the evolving landscape of mechanical circulatory support, the latest evidence from the DANGER and ECLS-SHOCK trials, and the complexities of patient selection. Key Topics Covered:1. The Evolution of ECLS in Cardiogenic Shock • The 25-year gap since the last positive cardiogenic shock trial. • How mechanical circulatory support expanded despite limited evidence.2. The DANGER Trial – Impella in AMI-Associated Cardiogenic Shock • Mechanism and function of the Impella device. • Trial results: 20% mortality reduction at 180 days. • Complications: Limb ischemia, hemolysis, and high costs. • Real-world application: Who actually qualifies?3. ECLS-SHOCK Trial – ECMO for Cardiogenic Shock • A "negative" trial, but a crucial wake-up call. • No mortality benefit but significantly higher complication rates. • Controversies: Inclusion of cardiac arrest patients and transition to destination therapy. • Future directions: Can patient selection improve outcomes?4. ECPR – Extracorporeal Support in Refractory Cardiac Arrest • Review of the ARREST, PRAGUE, and INCEPTION trials. • Why the evidence remains unclear and institution-dependent. • The role of high-volume ECMO centers and standardized pathways.5. The Future of ECLS – Cost, Ethics, and Decision-Making • How should institutions decide who gets ECMO? • The role of cardiogenic shock teams. • Could AI play a role in decision-making? • The challenge of resource allocation in a single-payer system.Key Takeaways:✅ Impella shows promise in carefully selected AMI shock patients but is costly and high-risk.✅ ECMO for cardiogenic shock remains controversial—patient selection is key.✅ ECPR is promising but needs further trials and structured implementation.✅ Cardiogenic shock management should be a team decision, not an individual one.
Cardiogenic shock is a devastating condition with a persistent 50% mortality rate. However, groundbreaking treatments and technologies are now dramatically improving survival odds. Join Shane Turner as he sits down with Jason Weatherly, Cardiogenic Shock Commercial Marketing Manager at Abiomed, to explore these advancements and the life-saving impact of the Impella device.Jason highlights the recent DanGer Shock RCT, which confirmed that Impella CP® with SmartAssist® improves survival by 12.7%. Together, they delve into how these medical breakthroughs are crucially linked to critical care transport, emphasizing innovative strategies that are essential for enhancing patient outcomes and shaping the future of cardiogenic shock treatment.In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNJason Weatherly, Cardiogenic Shock Commercial Marketing Manager at Abiomed
This week on The Beat, CTSNet Editor-in-Chief Joel Dunning speaks with Dr. Husam Balkhy, Professor of Surgery and the Director of Robotic and Minimally Invasive Cardiac Surgery at University of Chicago Medicine and President of The International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), about robotic totally endoscopic cardiac surgery procedures. They discuss potential ways to get the world to perform more robot-assisted surgeries, the building blocks to learning robotics, the future of learning robotics, and what to expect this year at the ISMICS 2025 Annual Meeting. They also explore Dr. Balkhy's new President's Series on CTSNet and provide insights into the first video of this series. Joel also highlights some of the videos in the CTSNet Resident Video Competition and the robotics vs VATS debate in Britain. Joel also reviews recent JANS articles on the impact of restricted chests on long-term lung function parameters following lung transplantation in patients with interstitial lung disease, determinants of inadequate cardioprotection in adult patients with left ventricular dysfunction, engineered heart muscle allografts for heart repair in primates and humans, and risk factor analysis for 30-day mortality after surgery for infective endocarditis. In addition, Joel explores open repair of descending thoracic and thoracoabdominal aortic aneurysms, totally 3D endoscopic third tricuspid valve replacement, and how to use the Impella for on-pump CABG in patients with low EF. Before closing, he highlights upcoming events in CT surgery. JANS Items Mentioned 1.) The Impact of Restricted Chests on Long-Term Lung Function Parameters Following Lung Transplantation in Patients With Interstitial Lung Disease 2.) Determinants of Inadequate Cardioprotection in Adult Patients With Left Ventricular Dysfunction 3.) Engineered Heart Muscle Allografts for Heart Repair in Primates and Humans 4.) Risk Factor Analysis for 30-Day Mortality After Surgery for Infective Endocarditis CTSNET Content Mentioned 1.) Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms 2.) Totally 3D Endoscopic Third Tricuspid Valve Replacement 3.) ICC 2024 | How I Use the Impella for On-Pump CABG in Patients With Low EF: Insertion, Intraoperative Management, and Weaning/Removal Other Items Mentioned 1.) President's Series With Husam Balkhy | ISMICS President 2.) ISMICS 2025 Annual Meeting 3.) Career Center 4.) CTSNet Events Calendar Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.
This is part two of a two part program covering some of the most listened to pieces we've done in the last 12 months. We'd love you to check out part 1, which is here: https://topmedtalk.libsyn.com/annual-digest-part-1-topmedtalk In this piece we cover and reflect upon the following podcasts: "The evolution of the Impella device in anesthesia, critical care, and perioperative medicine” https://topmedtalk.libsyn.com/the-evolution-of-the-impella-device-in-anesthesia-critical-care-and-perioperative-medicine-anes24 Is Trauma Informed Care part of your perioperative process? https://topmedtalk.libsyn.com/is-trauma-informed-care-part-of-your-perioperative-process-topmedtalk ROCKet Trial and PANDOS | Euroanaesthesia 2024 https://topmedtalk.libsyn.com/rocket-trial-and-pandos-tmt-at-ea24 "Patient Safety and Quality: New Standards in Anesthesia | #ANES24" https://topmedtalk.libsyn.com/patient-safety-and-quality-new-standards-in-anesthesia-anes24 And “Perioperative medicine in focus | EBPOM 24” https://topmedtalk.libsyn.com/perioperative-medicine-in-focus-ebpom-24
How does continuous learning and practical experience on the front lines make a difference in transport? Today's episode is hosted by critical care transport trainer, Jena Billig, who sits down with Josh Klute, an expert flight and ICU nurse, who credits specialized Impella training with his confidence and success in transport. Josh recounts his initial challenges and lack of confidence during his first Impella transport, contrasting it with the marked improvement in his skills and confidence after receiving targeted training. Jena and Josh discuss the necessity of continuous education and the value of tailored training in empowering transport teams, ultimately enhancing patient care and provider confidence.In this episode:Jena Billig, BSN, RN, CCRN, CFRN, Idaho Springs, ColoradoJosh Klute, EMT, Colorado Springs, Colorado
In this podcast, Dr. Valentin Fuster discusses a study on the use of the microaxial flow pump (Impella) in treating older patients with cardiogenic shock following a myocardial infarction. The findings suggest that while the Impella pump can reduce mortality in younger patients, its effectiveness diminishes in those over 77, highlighting the need for age-based patient selection to optimize outcomes in this complex condition.
Impella devices can be game-changers for cardiogenic shock, and members of the care team who manage these patients during transport require specific training and skills to optimize patient outcomes. Today, host Shane Turner is joined by Ryan Harmon to take an inside look at the systematic approach one clinician uses to troubleshoot issues and optimize these advanced therapies. Ryan Harmon is a clinical care coordinator in the emergency room with extensive experience as both a nurse and a paramedic.Harmon emphasizes the need for a systematic approach to troubleshooting issues, such as preload, afterload, and positioning, and the importance of managing medications to avoid complications. You'll also learn the value of having a knowledgeable partner and being prepared for potential challenges during transports.In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNRyan Harmon, Critical Care Transport Nurse/Paramedic, Lebanon, OH
Dr. Trina Augustin, assistant professor of both anesthesiology and perioperative medicine as well as emergency medicine takes us on a deep dive into the care of persons with aortic stenosis. In this chapter, Alex and Venk learn about how to use ultrasound to diagnose AS, the keys to resuscitation, the pathophysiology of this condition, as well as the value of consultative services and the potential interventions that they may unlock for these patients. Kickoff season 4 with this in depth reminder that sometimes the heart has many hidden perils beyond ACS. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @KatrinaJoyAugustin Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Lichtenstein DA, Meziere GA. Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure. Chest 2008; 134:117-125 Walsh MH, Smyth LM, Desy JR, Fischer EA, Goffi A, Li N, Lee M, St-Pierre J, Ma IWY. Lung Ultrasound: A Comparison of image interpretation accuracy between curvillinear and phased array transducers. Australia J Ultrasound Med, 26:150-156 Alzahrani H, Woo MY, Johnson C, Pageau P, Millington S, Thiruganasambandamoorthy V. Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers? Crit Ultrasound J. 2015 Apr 18;7:5. doi: 10.1186/s13089-015-0022-8. PMID: 25932319; PMCID: PMC4409610. Furukawa A, Abe Y, Morizane A, Miyaji T, Hosogi S, Ito H. Simple echocardiographic scoring in screening aortic stenosis with focused cardiac ultrasonography in the emergency department. J Cardiol. 2021 Jun;77(6):613-619. doi: 10.1016/j.jjcc.2020.12.006. Epub 2020 Dec 29. PMID: 33386216. Lin J, Drapkin J, Likourezos A, Giakoumatos E, Schachter M, Sarkis JP, Moskovits M, Haines L, Dickman E. Emergency physician bedside echocardiographic identification of left ventricular diastolic dysfunction. American Journal of Emergency medicine Ehrman RR, Russell FM, Ansari AH, Margeta B, Clary JM, Christian E, Cosby KS, Bailitz J. Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography? Am J Emerg Med. 2015 Sep;33(9):1178-83. doi: 10.1016/j.ajem.2015.05.013. Epub 2015 May 21. PMID: 26058890.2021;44:20-25 Del Rios M, Colla J, Kotini-Shah P, Briller J, Gerber B, Prendergast H. Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study. Crit Ultrasound J. 2018 Jan 25;10(1):4. doi: 10.1186/s13089-018-0084-5. PMID: 29372430; PMCID: PMC5785451. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Lauer B, Böhm M, Ebelt H, Schneider S, Werdan K, Schuler G; Intraaortic Balloon Pump in cardiogenic shock II (IABP-SHOCK II) trial investigators. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet. 2013 Nov 16;382(9905):1638-45. doi: 10.1016/S0140-6736(13)61783-3. Epub 2013 Sep 3. PMID: 24011548. Aksoy O, Yousefzai R, Singh D, Agarwal S, O'Brien B, Griffin BP, Kapadia SR, Tuzcu ME, Penn MS, Nissen SE, Menon V. Cardiogenic shock in the setting of severe aortic stenosis: role of intra-aortic balloon pump support. Heart. 2011 May;97(10):838-43. doi: 10.1136/hrt.2010.206367. Epub 2010 Oct 20. PMID: 20962337. Karatolios K, Chatzis G, Luesebrink U, Markus B, Ahrens H, Tousoulis D, Schieffer B. Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock. Hellenic J Cardiol. 2019 May-Jun;60(3):178-181. doi: 10.1016/j.hjc.2018.02.008. Epub 2018 Mar 21. PMID: 29571667. Gottlieb M, Long B, Koyfman A. Evaluation and Management of Aortic Stenosis for the Emergency Clinician: An Evidence-Based Review of the Literature. J Emerg Med. 2018 Jul;55(1):34-41. doi: 10.1016/j.jemermed.2018.01.026. Epub 2018 Mar 7. PMID: 29525246.
CardioNerds (Dr. Yoav Karpenshif – Chair of the CardioNerds Critical Care Cardiology Council) join Dr. Munim Khan, Dr. Shravani Gangidi, and Dr. Rachel Goodman from Tufts Medical Center's general cardiology fellowship program for hot pot in China Town in Boston. They discuss a case involving a patient who presented with stress cardiomyopathy leading to cardiogenic shock. Expert commentary is provided by Dr. Michael Faulx from the Cleveland Clinic. Notes were drafted by Dr. Rachel Goodman. A young woman presents with de novo heart-failure cardiogenic shock requiring temporary mechanical circulatory support who is found to have basal variant takotsubo cardiomyopathy. We review the definition and natural history of takotsubo cardiomyopathy, discuss initial evaluation and echocardiographic findings, and review theories regarding pathophysiology of the clinical syndrome. We also highlight complications of takotsubo cardiomyopathy, with a focus on left ventricular outflow obstruction, cardiogenic shock, and arrythmias. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls Takotsubo cardiomyopathy is defined as a reversible systolic dysfunction with wall motion abnormalities that do not follow a coronary vascular distribution. Takotsubo cardiomyopathy is a diagnosis of exclusion; patients often undergo coronary angiography to rule out epicardial coronary artery disease given an overlap in presentation and symptoms with acute myocardial infarction. There are multiple echocardiographic variants of takotsubo. Apical ballooning is the classic finding, but mid-ventricular, basal, and biventricular variants exist as well. Patients with takotsubo cardiomyopathy generally recover, but there are important complications to be aware of. These include arrhythmia, left ventricular outflow tract (LVOT) obstruction related to a hyperdynamic base in the context of apical ballooning, and cardiogenic shock. Patients with Impella devices are at risk of clot formation and stroke. Assessing the motor current can be a clue to what is happening at the level of the motor or screw. Notes What is Takotsubo Syndrome (TTS)? TTS is a syndrome characterized by acute heart failure without epicardial CAD with regional wall motion abnormalities seen on echocardiography that do not correspond to a coronary artery territory (see below).1 TTS classically develops following an acute stressor—this can be an emotional or physical stressor.1 An important feature of TTS is that the systolic dysfunction is reversible. The time frame of reversibility is variable, though generally hours to weeks.2 Epidemiologically, TTS has a predilection for post-menopausal women, however anyone can develop this syndrome.1 TTS is a diagnosis of exclusion. Coronary artery disease (acute coronary syndrome, spontaneous coronary artery dissection, coronary embolus, etc) should be excluded when considering TTS. Myocarditis is on the differential diagnosis. What are the echocardiographic findings of takotsubo cardiomyopathy? The classic echocardiographic findings of TTS is “apical ballooning,” which is a way of descripting basal hyperkinesis with mid- and apical hypokinesis, akinesis, or dyskinesis.3 There are multiple variants of TTS. The four most common are listed below:3(1) Apical ballooning (classic TTS)(2) Mid-ventricular variant(3) Basal variant (4) Focal variant Less common variants include the biventricular variant and the isolated right ventricular variant.3 Do patients with TTS generally have EKG changes or biomarker elevation? Patients often have elevated troponin, though the severity wall motion abnormalities seen on TTE i...
The Australian ERAS+ Conference and 2024 World Congress of Prehabilitation and Perioperative Medicine is an essential event for practitioners around the world. TopMedTalk were there and we will be bringing you a series of interviews with some of the key players and speakers. This piece is presented by Kate Leslie and Mike Grocott with their guest, David Watters, Alfred Deakin Professor of Surgery at Deakin University in Geelong, Victoria, Australia, based at the University Hospital Geelong, he is also Director of Surgery at Safer Care Victoria. -- TopMedTalk has ramped up its release schedule recently in response to growing demand for our recent conference coverage. Expect to see releases more frequently over the next few months. Ensure you are subscribed to us, so you don't miss out, and while you're here why not check out some of our new recent releases: ASA Presidents pass the baton | #ANES24 https://topmedtalk.libsyn.com/asa-presidents-pass-the-baton-anes24 The evolution of the Impella device in anesthesia, critical care, and perioperative medicine | #ANES24 https://topmedtalk.libsyn.com/the-evolution-of-the-impella-device-in-anesthesia-critical-care-and-perioperative-medicine-anes24
The American Society of Anesthesiologists (ASA)'s annual general meeting; Anesthesiology 2024. Exclusive cutting edge conversations recorded at the conference with some of the key speakers, guests and delegates. The discussion highlights the growing use of the Impella device in anesthesia and critical care, particularly for high-risk patients with severe heart failure or cardiogenic shock. Presented by Desiree Chappell, Monty Mythen and Mike Grocott with their guest Asad Usman, Anesthesiologist, critical care specialist and physician with Penn Medicine, Pennsylvania.
On this week's listener series episode, Jess shares the birth story of her daughter, the second of her four children. Jess' birth was mostly uncomplicated until immediately following her delivery via csection when breathing became difficult and her heart rate skyrocketed. Jess' heart was failing and her doctors scrambled to keep her alive. Through the use of ECMO and Impella, along with many other interventions and procedures Jess' life was saved. She shares more about what lead to her heart failure and subsequent cardiac arrest along with her two subsequent pregnancies/births in this episode. On this episode, you will hear:- Retrograde amnesia- High blood pressure in pregnancy- Cardiac arrest and the use of Impella and ECMO- Discovering a tumor and surgery following- Subsequent c-sections and healing processIf you have a birth trauma story you would like to share with us, click this link and fill out the form. For more birth trauma content and a community full of love and support, head to my Instagram at @thebirthtrauma_mama.Learn more about the support and services I offer through The Birth Trauma Mama Therapy & Support Services.
Are there different training protocols for maintaining expertise in Impella patient management when cases are infrequent? In this episode, Shane Turner is joined by Dustin McKeel, a seasoned Flight Paramedic and Clinical Base Educator from Memphis, to explore how the city's limited critical care options have spurred innovative training solutions.Learn how hands-on cadaver labs, real case studies, and rigorous simulations are equipping transport crews with the confidence and skills needed to handle complex patient scenarios effectively. Don't miss this insightful discussion on enhancing clinical capabilities and decision-making skills through advanced training methods.In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNDustin McKeel, FP-C, Flight Paramedic, Clinical Base Educator, Memphis, TN
This piece looks at the DanGer Shock Trial which examines the efficacy of the Impella device in reducing mortality in patients with acute myocardial infarction and cardiogenic shock. We explain how the device works, its implantation process, and the significant findings from the trial, including a notable reduction in six-month mortality with a number needed to treat (NNT) of eight. Despite higher rates of bleeding and renal filtration therapy in the Impella group, the trial provides strong evidence supporting its use in high-volume centers with trained personnel, emphasizing the importance of careful patient selection and timely intervention. Presented by Andy Cumpstey and Joff Lacey with their guest Vasileios Panneudales, an interventional cardiologist at Brompton and Harefield Hospitals.
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The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode931. In this episode, I'll discuss an alternative to a dextrose-based purge solution for patients with an Impella ventricular assist device that also need a PET scan. The post 931: Non-dextrose purge solution for patients with an Impella that require a PET scan appeared first on Pharmacy Joe.
Keeping Impella access sites exposed during movement and transport can make a critical difference in patient care, especially during short ground transports. In this episode, former flight nurse D.D. Finder sits down with trainer Jena Billig to recount a challenging case involving a heart failure patient on an Impella device for ECMO treatment. In this episode:Jena Billig, BSN, RN, CCRN, CFRN, Idaho Springs, ColoradoD.D. Finder, RN, BSN, CCRN, CFRN, Colorado
Welcome to Abiomed's Quarterly Update, where education is at the forefront. In this episode, host Shane Turner is joined by Jena Billig, primary trainer for the West region, to dive into the intricacies of the Impella pump's heparin-free purge system.Jena provides a comprehensive understanding while addressing misconceptions. She explains the importance of using a dextrose and water-based purge solution with heparin or sodium bicarb additive to prevent blood proteins from accumulating in the pump motor housing. Plus, Shane and Jena explore new features of the Impella Five, gen two catheter, designed to enhance safety for transport providers, including the intuitive catalog system and three-point fixation method.Whether you're a seasoned provider or new to the field, this episode offers valuable insights to improve patient care and transport practices. Tune in now to stay informed and elevate your knowledge of the Impella device and purge system!In this episode:Shane Turner, RN, CFRN, NRP, FP-C, CMTE, Chattanooga, TNJena Billig, BSN, RN, CCRN, CFRN, Idaho Springs, Colorado
ESC TV Today brings you concise analysis from the world's leading experts, so you can stay on top of what's happening in your field quickly. This episode covers: Cardiology This Week: A concise summary of recent studies Long-term beta blockers after myocardial infarction Pros and Cons of the microaxial pump in cardiogenic shock Snapshots Host: Perry Elliott Guests: Stephan Achenbach, Carlos Aguiar, Michael Boehm, Lene Holmvang Want to watch that episode? Go to: https://esc365.escardio.org/event/1151 Disclaimer This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC. Declarations of interests Stephan Achenbach, Michael Boehm, Lene Holmvang and Nicolle Kraenkel have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, AbbVie, Alnylam, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, Lilly, Novartis, Pfizer, Sanofi, Servier, Tecnimede. Davide Capodanno has declared to have potential conflicts of interest to report: Abbott Vascular, Novo Nordisk, Sanofi. Terumo, Medtronic. Emma Svennberg has declared to have potential conflicts of interest to report: institutional research grants from Abbott, Astra Zeneca, Bayer, Bristol-Myers, Squibb-Pfizer, Boehringer-Ingelheim, Johnson & Johnson, Merck Sharp & Dohme.
An Impella update, another TAVI vs SAVR trial, two studies on angina and PCI, another null substudy from REVIVED-BCIS, and semaglutide are the topics John Mandrola, MD, covers in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Impella Update CHRIP BCIS 3 https://classic.clinicaltrials.gov/ct2/show/NCT05003817 Danger-Shock Podcast https://www.medscape.com/viewarticle/1000675 II. TAVI vs SAVR Notion 2 Trial EHJ https://doi.org/10.1093/eurheartj/ehae331 DEDICATE-DZHK6 III. Angina and PCI Orbita 2 Sub-analysis Orbita Star https://www.jacc.org/doi/10.1016/j.jacc.2024.04.001 IV. Complete Revascularization Main REVIVED trial https://www.nejm.org/doi/full/10.1056/NEJMoa2206606 JACC Substudy https://www.jacc.org/doi/10.1016/j.jacc.2024.04.043 V. Semaglutide Semaglutide CV Benefits Irrespective of Weight Loss: 4-Year SELECT Data https://www.medscape.com/viewarticle/semaglutide-cv-benefits-irrespective-weight-loss-4-year-2024a100095z Nature Med substudy https://www.nature.com/articles/s41591-024-02996-7 SELECT Main paper https://www.nejm.org/doi/full/10.1056/NEJMoa2307563 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net
In this in-depth episode, cardiac nursing expert Sean from the Nurse Dose Podcast vividly illustrates how acute coronary syndromes, valve dysfunction, arrhythmias, and mechanical complications can all culminate in cardiogenic shock. You'll learn to spot the ominous signs like falling cardiac output, rising filling pressures, and poor end-organ perfusion. But most importantly, Sean equips you with the critical interventions - from revascularization to advanced circulatory support devices like balloon pumps and Impella pumps. Whether you're an ICU nurse or just want to solidify your knowledge of this high-stakes condition, this masterclass on cardiogenic shock is a must-listen. This episode is part of Nurses' PodCrawl 2024. Check out other episodes from these excellent nurse podcasters: Obstructive Shock: Critical Care Scenarios and Rapid Response RN Distributive shock: Straight A Nursing and How Not to Kill Your Patient Hypovolemic shock: The Q Word Podcast and Up My Nursing Game From this episode: Listen to the Nurse Dose Podcast Check out Nurse Dose on IG! @NurseDosePodcast Check out Nicole Kupchik's exam reviews and practice questions at nicolekupchikconsulting.com. Use the promo code UPMYGAME20 to get 20% off all products. Do you need help with your resume, interviewing, or need career coaching? Check out Sarah at New Thing Nurse: Get 15% off of her resume and cover letter templates using the promo code UPMYGAME Nursing students and new grad career services Experienced RN career services NP career services
Beyond logistics, safe transport requires effective communication, thorough planning and a commitment to continual learning. Today, Shane Turner is joined by Billy Thompson, a seasoned flight nurse with extensive experience in managing Impella patients. Plus, Shane and Billy explore key considerations such as assessing patient stability and properly securing the Impella console. Whether you're a seasoned transport professional or new to the field, this episode provides invaluable insights to ensure the safe and effective transport of these complex patients.
ACC Recap #1: DanGer Shock (plus a sobering JAMA research letter on Impella use), REDUCE-AMI, PREVENT, and EMPACT-MI are the topics John Mandrola, MD, covers in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. DanGer-Shock Trial Impella CP Improves Survival in STEMI, Cardiogenic Shock https://www.medscape.com/viewarticle/impella-cp-improves-survival-stemi-cardiogenic-shock-2024a10006kz Impella Saves Lives in Cardiogenic Shock, but Patient Selection Key https://www.medscape.com/viewarticle/1000659 Published DanGer Shock Study https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 JAMA Research letter https://jamanetwork.com/journals/jama/article-abstract/2817457 II. REDUCE-AMI Trial New Data Question Beta-Blockers Post-MI With Preserved EF https://www.medscape.com/viewarticle/new-data-question-beta-blockers-post-mi-preserved-ef-2024a10006y8 Beta-Blockers Post-MI Past Their Expiration Date: REDUCE-AMI https://www.medscape.com/viewarticle/1000663 REDUCE-AMI paper https://www.nejm.org/doi/full/10.1056/NEJMoa2401479 Meta-analysis: Beta Blockers for MI https://doi.org/10.1016/j.amjmed.2014.05.032 III. PREVENT Trial Preventive PCI for Vulnerable Plaques Reduces Cardiac Events https://www.medscape.com/viewarticle/preventive-pci-vulnerable-plaques-reduces-cardiac-events-2024a10006tc Preventive Coronary Stents: Not There Yet https://www.medscape.com/viewarticle/preventive-coronary-stents-not-there-yet-2024a10006yr PREVENT https://doi.org/10.1016/S0140-6736(24)00413-6 IV. EMPACT MI trial of Empagliflozin in the Post-MI setting Empagliflozin Fails to Reduce Events After Acute MI https://www.medscape.com/viewarticle/empagliflozin-fails-reduce-events-after-acute-mi-2024a10006kn EMPACT-MI: Another SGLT2 Inhibitor Miss in Post-MI Care https://www.medscape.com/viewarticle/1000684 EMPACT MI https://www.nejm.org/doi/10.1056/NEJMoa2314051 DAPA MI https://evidence.nejm.org/doi/full/10.1056/EVIDoa2300286 PARADISE MI https://www.nejm.org/doi/full/10.1056/NEJMoa2104508 Kaul thread https://x.com/kaulcsmc/status/1776611935842165029 Kaul paper https://www.ahajournals.org/doi/full/10.1161/circulationaha.116.022537 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net
Complete your knowledge around mechanical circulatory support (MCS) devices with this episode on Temporary MCS with Dr. Pankaj Jain from Sydney. This episode touches on cardiogenic shock before exploring the ins and outs of temporary MCS devices including the balloon pump, the impella devices and VA ECMO. DanGer Shock - a large RCT evaluating the Impella device - was released during the recording of this podcast so be sure to stick around for the discussion of DanGer Shock at the end of the podcast.As always, happy listening! If you have any suggestions or would like to join me on the show please reach out to me at rahul@mattersoftheheartcast.com
Memorial Hermann Life Flight created an innovative approach to improving patient care and transport efficiency for critically ill patients requiring Impella support. Go behind the scenes to discover how their program's transition to independently transporting patients with Impella devices has led to reduced transport times and enhanced patient outcomes. Plus, gain valuable insights and recommendations for implementing similar models in your transport program.In this episode:Diana Draehn, Abiomed Critical Care Team Trainer, Dallas, TXRudy Cabrera, Director and Chief Flight Nurse, Memorial Hermann Life FlightTony Herrera, Clinical Educator, Memorial Hermann Life FlightNPS-4298
As members of Abiomed's Critical Care Transport Team, we know that every transport is a lifeline, and every moment counts in our mission to recover hearts and save lives. Inside Impella: Transport Talks is a podcast where we equip you with knowledge and confidence as you transport Impella patients. Subscribe now for monthly episodes offering best practices, valuable lessons, and camaraderie. Let us be your companion as you focus on what truly matters: patient recovery and saving lives beyond the hospital walls.
Host Sarah Lorenzini and Christian Guzman APRN are back to conclude this three-part heart failure series by examining the use of mechanical circulatory support for cardiogenic shock. This episode expands on the topics covered in previous parts, focusing on the application of mechanical circulatory support methods like the intra-aortic balloon pump, Impella, CentriMag, LVADs, and ECMO.Christian and Sarah review the risks and benefits of each device, when to use them, and the key factors that impact these decisions. They also address the ethical challenges of ECMO, including the clinical judgment involved when determining who's a good candidate and when to escalate care.By the end of this episode, you'll understand how these devices function, their critical role in managing cardiogenic shock in heart failure patients, and the value nurses bring to a multidisciplinary team.Tune in for a knowledge-packed finale of this comprehensive heart failure series!Topics discussed in this episode:The role of mechanical circulatory support devicesBenefits and risks of the intra-aortic balloon pump and Impella deviceHow to properly use Impella devicesCentriMag and Left Ventricular Assist Devices (LVADs)The evolution of permanent LVADsExtracorporeal Membrane Oxygenation (ECMO) for cardiac supportChallenges and ethical considerations of ECMOThe importance of nursing knowledge and confidenceConnect with Christian Guzman APRN on Instagram:https://www.instagram.com/thenerdynursepractitioner/Watch this episode on The Rapid Response RN YouTube Channel! https://www.youtube.com/@therapidresponsern/videosMentioned in this episode:Coming Soon! Rapid Response Academy: The Heart and Science of Caring for the SickClick here to learn more about the community that Sarah is building: https://www.rapidresponseandrescue.com/coming-soon-rapid-response-academy Rapid Response and Rescue Intro CourseCONNECT
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode874. In this episode, I’ll discuss what Impella purge solution can be used if the patient has a contraindication to heparin. The post 874: How Well Does a Bicarb-Based Impella Purge Solution Work for Patients With Contraindications to Heparin? appeared first on Pharmacy Joe.
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode874. In this episode, I’ll discuss what Impella purge solution can be used if the patient has a contraindication to heparin. The post 874: How Well Does a Bicarb-Based Impella Purge Solution Work for Patients With Contraindications to Heparin? appeared first on Pharmacy Joe.
Anika Therapeutics received the final FDA 510(k) clearance for its Integrity implant system for improving outcomes in rotator cuff repair procedures through biologic healing. The hyaluronic acid-based patch augments an injured tendon, promoting rotator cuff healing. Fast Five hosts Sean Whooley and Danielle Kirsh delve into how the device works and what the regulatory nod means for Anika. Ventricular assist devices save lives and another one may soon be entering the fold. MagAssist won FDA breakthrough device designation for its NyokAssist VAD, which provides mechanical circulatory support for high-risk percutaneous interventions. Find out what led the agency to grant this designation. Axonics will soon have a new chief financial officer after longtime executive Dan Dearen notified the company of his intent to retire. The company already picked a replacement, promoting from within to fill the role. Learn more about Axonics' selection and what the new executive brings to the company in terms of experience and know-how. In another executive change, Tandem Diabetes Care announced that its chief commercial officer plans to resign from the role. Brian B. Hansen had been the company's CCO since 2016. Whooley and Kirsh take a look at Hansen's background and the terms of a separation agreement struck between Hansen and the automated insulin delivery technology developer. For the third time in as many months, Abiomed issued a correction for its Impella heart pumps. The FDA Class I recall pertains to the instructions for use for the system. The hosts break down the numbers behind this recall and what kind of mitigations Abiomed is implementing to remedy the issue. Check out the show notes for links to the stories we discussed today at MassDevice.com/podcast.
Understanding the Physics of Intra-Aortic Balloon Pumps. Learn the 8 phases of the cardiac cycle and how to accurately time the IABP. IABP, Impella, and ECMO; when are they appropriate to use? "Mastering Intra-Aortic Balloon Pumps: Decoding the Physics and Timing for Optimal Cardiac Support" Welcome to our channel, where we delve into the fascinating world of cardiovascular physiology! In this comprehensive video, we invite you to embark on an enlightening journey to understand the physics of Intra-Aortic Balloon Pumps (IABP) and explore the critical role they play in supporting the cardiac cycle.
CardioNerds co-founder Dr. Amit Goyal and episode leads Dr. Jaya Kanduri (FIT Ambassador from Cornell University) and Dr. Jenna Skowronski (FIT Ambassador from UPMC) discuss Complications of acute myocardial infarction with expert faculty Dr. Jeffrey Geske. They discuss various complications of acute MI such as cardiogenic shock, bradyarrythmias, left ventricular outflow tract obstruction, ruptures (papillary muscle rupture, VSD, free wall rupture), and more. Show notes were drafted by Dr. Jaya Kanduri. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy. The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen. CardioNerds Beyond the Boards SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Complications of Acute Myocardial Infarction Sinus tachycardia is a “harbinger of doom”! The triad for RV infarction includes hypotension, elevated JVP, and clear lungs. These patients are preload dependent and may need fluid resuscitation despite having an elevated JVP. Bradyarrythmias in inferior MIs are frequently vagally mediated. The focus should be on medical management before committing to a temporary transvenous pacemaker, such as reperfusion, maintaining RV preload and inotropy, avoiding hypoxia, and considering RV-specific mechanical circulator support (MCS). Worsening hypotension with inotropic agents (e.g., dobutamine, epinephrine, dopamine, norepinephrine) after a large anterior-apical MI should raise suspicion for dynamic left ventricular outflow tract obstruction due to compensatory hyperdynamic basal segments. The myocardium after a late presentation MI is as “mushy as mashed potatoes”! Need to look out for papillary muscle rupture, VSD, and free wall rupture as potential complications. Papillary muscle rupture can occur with non-transmural infarcts, and often presents with flash pulmonary edema. VSDs will have a harsh systolic murmur and are less likely to present with pulmonary congestion. Free wall rupture can present as a PEA arrest. All of these complications require urgent confirmation on imaging and early involvement of surgical teams. Notes - Complications of Acute Myocardial Infarction How should we approach cardiogenic shock (CS) in acute myocardial infarction (AMI)? Only 10% of AMI patients present with CS, but CS accounts for up to 70-80% of mortality associated with AMI, usually due to extensive LV infarction with ensuing pump failure. Physical examSinus tachycardia is considered a “harbinger of doom”, when the body compensates for low cardiac output by ramping up the heart rateThe presence of sinus tachycardia and low pulse and/or blood pressure in a patient with a large anterior MI should raise suspicion for cardiogenic shockBe wary of giving IV beta blockers in this situation as negative inotropes can precipitate cardiogenic shock (Commit Trial) When interpreting a patient's blood pressure in the acute setting, it is helpful to know their baseline blood pressure and if they have a significant history of hypertension. Patients
Abbott has now seen two quarters in a row of double-digit organic sales growth in its underlying business. Now the company is betting on its productive, innovative pipeline to build momentum. Fast Five hosts Sean Whooley and Danielle Kirsh go over the full performance of the company and how each of its segments performed. Johnson & Johnson MedTech posted revenues of $7.9 billion, marking a 12.9% improvement year-over-year. Learn what the growth drivers were for the MedTech segment and what analyst's think about the second-quarter results. The initiation of Magnus Medical's neurostim trial marks a significant milestone in the field of mental health treatment, offering hope for patients with treatment-resistant depression. Whooley and Kirsh discuss the company's technology and the potential impact it could have on the treatment of treatment-resistant depression. MediView XR announced this week that it received FDA 510(k) clearance for its XR90 augmented reality-based visualization and navigation platform. Find out the purpose of the AR platform and how it works to address the limitations of traditional medical imaging technologies. Johnson & Johnson's Abiomed unit issued another recall for some of its Impella heart pumps. The recall is for TAVR-related devices. Whooley explains the reason for the recall, the risks involved and provides comments from Abiomed on the situation. Check out the show notes for links to the stories we discussed today at MassDevice.com/podcast.
Hey everyone! Just a quick update for y'all! My first book has been published on Amazon! "From Novice to Nurse: Empowering Reflections" My new 11-page Hemodynamic Crash Course is now available HERE along with all my other cheat sheets for the Balloon Pump, Impella, and more! We have got some great episodes in the works so get subscribed so you are notified when they are released. Talk to y'all soon!
Starting HF meds during hospitalization for HF, Impella, testosterone, and colchicine are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Starting HF Meds During Hospitalization for HF Starting Indicated Heart Failure Meds In-Hospital: Progress, Opportunities https://www.medscape.com/viewarticle/993539 - Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction https://www.jacc.org/doi/full/10.1016/j.jchf.2023.04.015 II. Impella - Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock https://jamanetwork.com/journals/jamacardiology/fullarticle/2806562 - Evidence Generation for Novel Cardiovascular Devices—Putting the Horse Back in Front of the Cart https://jamanetwork.com/journals/jamacardiology/fullarticle/2806565 III. Testosterone Big Trial Reassures on Heart Safety of Testosterone in Men https://www.medscape.com/viewarticle/993322 - Cardiovascular Safety of Testosterone-Replacement Therapy https://www.nejm.org/doi/full/10.1056/NEJMoa2215025 IV. Colchicine for CV Disease Low-Dose Colchicine Approved for CVD: Now What? https://www.medscape.com/viewarticle/993578 - Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction https://www.nejm.org/doi/full/10.1056/nejmoa1912388 - Colchicine in Patients with Chronic Coronary Disease https://www.nejm.org/doi/full/10.1056/nejmoa2021372 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net
Unsere Kardiologen haben sich für ihr Herzkatheterlabor ein neues Spielzeug zugelegt: Die Impella. Grund für mich, erst mal klar zu bekommen, worum es sich handelt und was man dabei beachten muss. An meinen Erkenntnissen möchte ich euch hier teilhaben lassen. Und wenn ihr Tipps oder Einlassungen aus euren Erfahrungen hier runter posten wollt, seid … Weiterlesen
Impella, digital health, low-value processes, are tricuspid valve interventions with pacing leads are the topics Dr. John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Impella Class I Recall FDA Class I Recall for Some Abiomed Impella Heart Pumps https://www.medscape.com/viewarticle/992845 - A Prospective, Randomized Clinical Trial of Hemodynamic Support With Impella 2.5 Versus Intra-Aortic Balloon Pump in Patients Undergoing High-Risk Percutaneous Coronary Intervention https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.112.098194 - Percutaneous Mechanical Circulatory Support Versus Intra-Aortic Balloon Pump in Cardiogenic Shock After Acute Myocardial Infarction https://doi.org/10.1016/j.jacc.2016.10.022 https://www.sciencedirect.com/science/article/pii/S0735109716367675?via%3Dihub - The Evolving Landscape of Impella Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention With Mechanical Circulatory Support https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.119.044007 - Association of Use of an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump With In-Hospital Mortality and Major Bleeding Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock https://jamanetwork.com/journals/jama/fullarticle/2761003 - Danish Cardiogenic Shock Trial (DanShock) https://clinicaltrials.gov/ct2/show/NCT01633502 II. Wearable Devices - Use of Wearable Devices in Individuals With or at Risk for Cardiovascular Disease in the US, 2019 to 2020 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805753 doi:10.1001/jamanetworkopen.2023.16634 - Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial https://doi.org/10.1016/S0140-6736(21)01698-6 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01698-6/fulltext - Prevalence and Prognostic Significance of Bradyarrhythmias in Patients Screened for Atrial Fibrillation vs Usual Care https://jamanetwork.com/journals/jamacardiology/fullarticle/2801362 III. The Cost of Quality Measures - The Volume and Cost of Quality Metric Reporting https://jamanetwork.com/journals/jama/fullarticle/2805705 - Goodhart's law https://en.wikipedia.org/wiki/Goodhart%27s_law IV. Tricuspid Valve Interventions and Pacing Leads Leadless Dual-Chamber Pacemaker Clears Early Safety, Performance Hurdles https://www.medscape.com/viewarticle/992464 - Transcatheter Tricuspid Valve Replacement With the EVOQUE System: 1-Year Outcomes of a Multicenter, First-in-Human Experience https://www.jacc.org/doi/10.1016/j.jcin.2022.01.280 - Effects of Implantable Cardioverter-Defibrillator Leads on the Tricuspid Valve and Right Ventricle: A Randomized Comparison of Transvenous versus Subcutaneous Leads https://eppro01.ativ.me/src/EventPilot/php/express/web/planner.php?id=HRS23&utm_source=heartrhythm&utm_medium=nav-button&utm_campaign=hr23-webtracking - Management and Outcomes of Transvenous Pacing Leads in Patients Undergoing Transcatheter Tricuspid Valve Replacement https://www.jacc.org/doi/10.1016/j.jcin.2020.04.054 - TRILUMINATE trial -- Transcatheter Repair for Patients with Tricuspid Regurgitation https://www.nejm.org/doi/full/10.1056/NEJMoa2300525 https://www.nejm.org/doi/full/10.1056/NEJMoa2300525 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net
Sparrow BioAcoustics' FDA clearance for their smartphone stethoscope marks a significant advancement in remote patient monitoring and telehealth. This innovative technology allows healthcare professionals to capture and analyze heart and lung sounds using a smartphone, enabling more accessible and convenient monitoring of patients' respiratory health. Fast Five hosts Sean Whooley and Danielle Kirsh have all the details. The FDA clearance of GE Healthcare's Sonic DL AI technology for expediting MRI scans is another significant breakthrough in medical imaging. This platform could enable new imaging paradigms, including high-quality cardiac MRI in a single heartbeat. Whooley explains how the technology works and what this could mean for cardiac imaging and healthcare. Masimo's FDA clearance of its vital sign monitor highlights the importance of telehealth in today's healthcare settings. This wearable device provides continuous monitoring of key vital signs, such as heart rate, oxygen saturation, and respiratory rate, enabling healthcare professionals to track patients' health parameters outside of traditional clinical settings. Kirsh and Whooley discuss the technology and how it works. Novo Nordisk's potential acquisition of a majority stake in BioCorp demonstrates the growing interest of pharmaceutical companies in digital health solutions. It follows Bayer's announcement last week that it was making a move to digital health. Whooley explains the financial details of the deal and how optimistic executives are at both companies. Abiomed's recall of certain Impella 5.5 with SmartAssist devices is an important step in ensuring patient safety and maintaining quality standards. Product recalls are a vital aspect of post-market surveillance and risk management, aiming to address any potential issues that may arise with medical devices. The Fast Five hosts share the details of the recall, including how many devices are affected and if there have been any reported complaints related to the device. Check out the show notes at MassDevice.com/podcast.
An HRS meeting recap, Impella failure, sacubitril/valsartan, the purpose of trials, and a major breakthrough in evidence generation are the topics discussed by John Mandrola, MD in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. HRS Meeting Recap II. Impella in VT ablation - First-in-human Experience with Impella 5.0/5.5 for High-Risk Patients with Advanced Heart Failure Undergoing VT Ablationhttps://www.jacc.org/doi/10.1016/j.jacc.2023.05.012 III. Sacubitril/Valsartan ARNI Bests ARB to Reduce NT-proBNP in Stabilized Preserved-EF HF https://www.medscape.com/viewarticle/992461 - Angiotensin-Neprilysin Inhibition in Patients With Mildly Reduced or Preserved Ejection Fraction and Worsening Heart Failure https://www.jacc.org/doi/10.1016/j.jacc.2023.04.019 - Angiotensin–Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction https://www.nejm.org/doi/full/10.1056/nejmoa1908655 - Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF https://doi.org/10.1093/eurheartj/ehad344 - Bogdan Tweet https://twitter.com/bogdienache/status/1660356776204595201?s=20 IV. Big Change in Reporting of Medical Evidence – Elan Trial - Early versus Later Anticoagulation for Stroke with Atrial Fibrillationhttps://www.nejm.org/doi/full/10.1056/NEJMoa2303048 - Early versus Late initiation of direct oral Anticoagulants in post-ischaemic stroke patients with atrial fibrillatioN (ELAN): Protocol for an international, multicentre, randomised-controlled, two-arm, open, assessor-blinded trial https://doi.org/10.1177/23969873221106043 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact: news@medscape.net
On May's JHLT: The Podcast, we feature two manuscripts from the May issue of The Journal of Heart and Lung Transplantation. First, the editors explore a study entitled “Donor hyperoxia is a novel risk factor for severe cardiac primary graft dysfyunction,” which comes from Kransdorf and colleagues at Cedars Sinai Medical Center in Los Angeles. The editors welcome first author Evan Kransdorf, MD, PhD, to share how he transitioned from oncology to heart failure and transplantation, and to talk about the findings of the study. The Digital Media Editors want to know how machine learning came to be a part of the study, what other donor-specific predictors might contribute to severe PGD, and whether DCD and DBD donors had different outcomes. Next, the editors welcome first author Danny Ramzy, MD, PhD, from the UTHealth McGovern School of Medicine in Houston to discuss the paper, “Improved clinical outcomes associated with the Impella 5.5 compared to the Impella 5.0 in contemporary cardiogenic shock and heart failure patients.” The digital media editors dig in with Dr. Ramzy on why Impella 5.5 has better outcomes and if this outcome holds in multivariable models, why the survival outcomes were so much higher than published survivals for patients with cardiogenic shock, and what follow up studies might get the answers they're looking for. Follow along at www.jhltonline.org/current, or, if you're an ISHLT member, log in at ishlt.org/journal-of-heart-lung-transplantation. Don't already get the Journal and want to read along? Join the International Society of Heart and Lung Transplantation at www.ishlt.org for a free subscription, or subscribe today at www.jhltonline.org.
Please join author Petr Ostadal and Associate Editor Dharam Kumbhani as they discuss the article "Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Peder Myhre: And I'm Dr. Peder Myhre, social media editor from Akershus University Hospital and University of Oslo in Norway. And today Carolyn will have such an interesting feature discussion. We are going to look into the use of ECMO to treat patients with cardiogenic shock, the results of the ECMO-CS randomized clinical trial. Isn't that interesting? Dr. Carolyn Lam: Awesome. Can't wait. But I suppose you're going to tell us about some papers in the issue first. I'm getting my coffee. Dr. Peder Myhre: Yeah, go ahead. Because first we're going to talk about a very interesting paper that relates to diabetes and the progression of coronary artery disease. So as you know, Carolyn, diabetes remains associated with an increased risk of cardiovascular morbidity and mortality. And although the absolute risk difference between patients with and without diabetes have declined over the past 20 years, we still don't know what is the diabetes associated differences in coronary plaque morphology and lipid content. Dr. Carolyn Lam: It's true. That's a very interesting question. And will you tell us more? Dr. Peder Myhre: Yeah. So the investigators in the prospect two study who enrolled patients exclusively from Denmark, Norway in Sweden who presented with biomarker positive MI and assessed both culprit lesions and untreated non-culprit lesions in these patients. And then they stratified the patients by diabetes status and examined with three vessel quantitative coronary angiography and near infrared spectroscopy and intravascular ultrasound imaging after successful percutaneous coronary intervention. Dr. Carolyn Lam: Okay, that's deep investigation. And what did they find? Dr. Peder Myhre: So diabetes was present in about 12% of patients and during a median or 3.7 year follow up, MACE occurred almost twice as free frequently in patients with versus without diabetes. And that was primarily due to an increased risk of MI related to culprit lesion stenosis and non-culprit relation related spontaneous MI. However, baseline prevalence of high-risk plaque characteristics was similar for patients with versus without diabetes, concerning culprit and the non-culprit lesions and in multi-variable models, diabetes was associated with MACE in lesions but not with prevalence of high-risk plaque characteristics. So Carolyn, the authors conclude that diabetes related plaque characteristics that might underlie the increased risk were not identified by multimodal imaging. Dr. Carolyn Lam: Oh, I just love studies like that so elegant with just a really, really intriguing results that make us ask more important questions. Love it. Thank you. Well, the next paper is also about myocardial infarction, but this time looking at the fibrotic remodeling after myocardial infarction because we know that MI induces a repair response that ultimately generates a stable fibrotic scar. And although the scar is important to prevent cardiac rupture, excessive pro-fibrotic response impairs optimal recovery because it promotes a development of non-contractual fibrotic areas. So would it be possible to regulate the expansion of cardiac fibroblast after MI through a paracrine action on the cardiac stromal cells? So the authors led by corresponding author Dr. Hulot from University of Paris performed a bioinformatic secretome analysis of cardiac stromal PW1 positive cells isolated from normal and post MI mouse hearts to identify novel secreted proteins. And they found that first cardiac PW1 positive stromal cells responded to myocardial infarction by secreting factors that promoted the proliferation and activation of resident fibroblasts and one such factor growth differentiation factor three or GDF3 was highly upregulated in the ischemic hearts and promoted a high induction of fibroblast proliferation via interaction with TGF beta receptors and activation of SMAD1/5 and SMAD2/3 signaling cascades. The upregulation of GDF3 was detected in the plasma of mice and humans following MI and high levels of plasma GDF3 in the days following MI predicted adverse outcomes measured six months later including cardiac dilation and limited recovery of contractile function in humans. Dr. Peder Myhre: Oh, that's so interesting. We already know GDF15 were very well, but now we hear about GDF3 in predicting fibrotic remodeling post myocardial infarction. So Carolyn, what are the clinical implications of these findings? Dr. Carolyn Lam: Exactly, Peder, in fact you said it. So the detection of high circulating GDF3 in plasma may serve as a novel biomarker of adverse fibrotic remodeling in heart tissue. That's one. And next the measurement of GDF3 plasma levels in the early post MI phase may allow for the identification of patients within an increased risk of severe myocardial fibrosis and heart failure and therefore could guide specific disease management. Dr. Peder Myhre: Thank you. That was an excellent summary of the paper, Carolyn. And now I'm going to look into a paper that relates to the important issue of arteriosclerosis following heart transplantation because as you know, transplant arteriosclerosis characterized by concentric and diffuse narrowing of vastly lumen is a major complication in long-term survivors of heart transplant patients. And increased lymph flow from donor heart to host lymph nodes has been reported to play a role in transplant arteriosclerosis. But how lymphangiogenesis affects this process is unknown. The authors of this paper, which comes to us from corresponding author Sue from Sejong University, transplanted vascular allografts between various combinations of mice including mice with severe combined immune deficiency and studied the lymphatic vessels within the grafted arteries. Dr. Carolyn Lam: Wow, that is really cool. Studying lymphatics and lymphangiogenesis in atherosclerosis. Interesting. What did they find, and what are the clinical implications? Dr. Peder Myhre: So Carolyn, lymphangiogenesis within allograft vessels began at the anastomotic sites and extended from preexisting lymphatic vessels in the host. Tertiary lymphatic organs were identified in transplanted arteries at the anastomotic site and lymphatic vessels expressing CCL21 were associated with these immune structures. Fibroblasts in the vascular allografts released VEGFC, which stimulated lymphangiogenesis into the grafts and inhibition of VEGFC signaling inhibited lymphangiogenesis, neointima formation and adventitial fibrosis of vascular allografts. And these studies identified VEGFC released from fibroblasts as signal stimulating lymphangiogenesis extending from the host into the vascular allografts. So, Carolyn, the authors conclude that the formation of lymphatic vessels play a key role in the immune response to vascular transplantation and inhibition of lymphangiogenesis may be a novel approach to prevent transplant atherosclerosis. Dr. Carolyn Lam: Wow, that is super interesting. Thanks, Peder. While also in this issue, there's an exchange of letters between Drs. Tanaka and Schulze regarding SGLT2 inhibitor treatment in acute decompensated heart failure. Why do we initiate it early? There's also a really nice On My Mind paper by Dr. Schiattarella on Cardiometabolic HFpEF. Is it the NASH of the heart? Dr. Peder Myhre: Oh, that's interesting. We also have some cardiology news by our own Bridget Kuehn entitled “No Benefit Seen for Nighttime Dosing Over Morning Dosing for Antihypertensive Medications.” And this is a summary of the time trial, which was presented at European Society of Cardiology Congress in 2022. And finally, Carolyn, we have a Research Letter entitled “Stepwise Generation of Human-Induced Pluripotent Stem Cell Derived Cardiac Parasites to Model Coronary Microvascular Dysfunction” by Dr. Joseph Wu from Stanford University School of Medicine. Dr. Carolyn Lam: While cool, Peder. But now I'm so excited to hear about the ECMO-CS randomized trial. Let's go. Dr. Greg Hundley: Welcome listeners to this February 7th feature discussion and we have with us today Dr. Petr Ostadal from Na Homolce Hospital in Prague in the Czech Republic and our own associate editor, Dr. Dharam Kumbhani from UT Southwestern in Dallas, Texas. Welcome, gentlemen. Well, Petr, we'll start with you. Can you describe for us some of the background information that really led you to perform this study, and what was the hypothesis that you wanted to address? Dr. Petr Ostadal: According to the current guidelines from the management for the management of cariogenic shock, it should be considered administration of inotropes and vasopressor for hemodynamic stabilization, or it may be considered administration of inotropes and vasopressors and it should be considered the use of short-term mechanical circulatory support. And the aim of the ECMO-CS trial was to compare early conservative therapy with inotropes and vasopressors and immediate implementation of ECMO in patients with the rapidly deteriorating or severe cardiogenic shock. The hypothesis of the ECMO-CS trial was that immediate implantation of ECMO in patients with cardiogenic shock and critical hemodynamic condition will be associated with improved outcomes. Dr. Greg Hundley: Very nice. Can you describe for us this study population and then also what study design did you use to address your hypothesis? Dr. Petr Ostadal: We try to select patients who can really profit from the early ECMO implantation, and we define two categories of patients. First category where the patients with rapidly deteriorating cardiogenic shock corresponding to current sky stage D or E. This patient should have evidence of left ventricle pump failure as left ventricle ejection fraction below 35% or ejection fraction 35 to 55 in case of severe mitral regurgitation or aortic stenosis. And this patient also should require a repeated both of vasopressors to maintain mean arterial pressure about 50 millimeters of mercury. The second category where the patients with severe cardiogenic shock corresponding to current sky stage D and this patient should have the criterion of a hemodynamic conditions which was cardiac index less than 2.2 or systemic blood pressure below 100 millimeters of mercury in both situation with higher doses of inotropes and vasopressors. And in case of a low systolic blood pressure, also the evidence of left ventricle pump failure based on ejection fractional below 35 or ejection fraction 35 to 55 in case of severe mitral regurgitation of aortic stenosis. The second criteria for the metabolic criteria, that was the evidence of tissue hypoperfusion and this was defined as a higher lactate above three millimeters per litter or low ScvO2 below 50%. And the third criterion was exclusion of hypovolemia, and this was based on central venous pressure or pulmonary artery wedge pressure. So this was the major inclusion criteria in the ECMO trial. The study population was not defined based on theology of cardiogenic shock, but just on severity of cardiogenic shock. Dr. Greg Hundley: Very nice. And so your design, did you have a one-to-one randomization, or how did that work? And then also how many subjects did you include in this important trial? Dr. Petr Ostadal: The patients were randomized in one-to-one ratio to immediate implementation of ECMO or to early conservative therapy. But it is important to point out that in the early conservative therapy downstream use of ECMO was allowed in case of further hemodynamic worsening defined as increase of what lactate by three millimeters per litter. We enrolled 122 patients, 61 were randomized to early ECMO and 61 to early conservative strategy. Five patients were excluded due to absence of informed consent and finally 58 patients were analyzed in the early ECMO or immediate ECMO arm and 59 patients were analyzed in the early conservative arm. Dr. Greg Hundley: Sounds great Petr. And then tell us and describe your study results. Dr. Petr Ostadal: The primary endpoint was composite of death from any cause, resuscitated circulatory RS and implementation of another mechanical circulatory support including ECMO in the early conservative arm at 30 days. And there was no difference in the primary endpoint with P 0.2221 and has a ratio of 0.72 with a 95% confidence in interval 0.46 to 1.12. There was also no difference in the incidence of death from any cause. 50% in the immediate ECMO arm and 28%, 47.5% in the early conservative arm. There was no difference in the incidence of resuscitated circulatory arrest, 10.3 in the immediate ECMO arm and 13.6 in the early conservative arm. Less patient required another mechanical circulatory support in the early ECMO arm through 17.2 in comparison with 42.4% in the early conservative arm and downstream ECMO was used in 39% of patients in the early conservative arm. Dr. Greg Hundley: Very nice. So similar results both immediately and then 30 days later for both arms. And I think that last point that you make is very interesting. 39% of the individuals randomized to the conservative arm went on to receive VA-ECMO. Well, listeners next, we're going to turn to one of our associate editors and Dharam, you have many papers that you see. How do we put the results that Petr has just described really in the context of management of shock and results that have been published previously? Dr. Dharam Kumbhani: Yeah, Greg, thank you. And Petr, thank you for this important paper and again, I'm really honored to be here on behalf of Circulation on the Run. So again, want to congratulate the authors for really an important study. I think in terms of context, what is really interesting is the use of ECMO, particularly VA-ECMO for patients with shock has really skyrocketed. And it is interesting that this expansion has occurred in the absence despite, I guess high quality clinical trials, this trial certainly fills an important void. Although it is a small patient population, it is randomized, it is a largest randomized trial to date on this important population. And so I think most of the studies that have been done so far have been done using observational data sets which have sort of inherent limitations. So I certainly want to congratulate you on trying to study this very challenging population because in sort of that acute setting, it's frequently very hard to get patients randomized. So just broadly in that context, I think at the same time this study does sort of pose some important questions and sort of perhaps leads, just given the limitations of the sample size does sort of leave a few unanswered questions. So one question I have is, Petr, in addition to the 40% crossover rate is obviously important as Greg pointed out. The other thing is it appears that the use of other mechanical support during the conduct of this trial was also close to 40%, about 42%. So pretty much everybody in the conservative arm ended up with some kind of mechanical support. Now, at least in the last few years, a concept that has gained a lot of traction is a concept of a shock team where a number of providers with particular expertise from different disciplines would get together and sort of decide next steps was a shock team sort of part of the decision-making, especially for the conservative arm. Dr. Petr Ostadal: Thank you for this question. The situation is maybe a little bit more simple in the Czech Republic here, the cardiologist are responsible for the acute cardiac care, usually competent and experience not only for the diagnosis and examinations and monitoring of patients in cardiogenic shock, but also experience in insertion and management of the mechanical circulatory support. So here this attending cardiologist competent to manage this patient from different sites from the manage not only the conservative therapy but also the mechanical circulatory support therapy in these patients. So in this respect, this is more simple situation in the Czech Republic. Dr. Dharam Kumbhani: I just had a very quick question about, and I don't know if you want to include this, but Petr, I was curious, were patients with cardiac arrest, I know you mentioned sky shocks in were patients with cardiac arrest on the field or in the hospital included? Dr. Petr Ostadal: Thank you for this excellent question. And in comparison, with other trials comparing the or focusing on patients with cardiogenic shock in the ECMO-CS trials, cardiac arrest survivors were excluded. And the reason was that the brain damage, which is the major cause of death in these patients cannot be influenced by ECMO insertion. And second, in majority of patients after cardiac arrest, if there is a presence of shock, there is frequently combined shock with important peripheral component. And again, it cannot be assumed that this peripheral component can be reversed by ECMO implantation. So in the ECMO-CS trial, the cardiac arrest survivors were excluded from that enrollment. Dr. Greg Hundley: Well, thank you so much Petr. Petr, what do you think is the next study to be performed really in this area of research? Dr. Petr Ostadal: I think that we are happy because several other clinical trials focusing on the mechanical circulatory support in patients with cardiogenic shock underway. And there are other trials focused on ECMO and trials a bit focused on combination of ECMO with balloon pump and trials focused on Impella. So I think in the very close time we will be able to see the results of these current running trials1. Dr. Greg Hundley: And Dharam, do you have anything to add? Dr. Dharam Kumbhani: No, I agree completely with Petr. I think this is a very exciting field. I know there's a lot of interest in doing well conducted clinical trials in this space. And so certainly, I think the future is bright for investigation in this field. Dr. Greg Hundley: Very nice. Well, listeners, we want to thank Dr. Petr Ostadal from Prague in the Czech Republic and our own associate editor, Dr. Dharam Kumbhani from Dallas, Texas for bringing us this study highlighting that immediate implementation of VA-ECMO in patients with rapidly deteriorating, or severe cardiogenic shock did not improve clinical outcomes compared to an early conservative strategy that permitted downstream use of VA-ECMO in the case when the patient's hemodynamic status worsened. Well, on behalf of Carolyn, and Peder, and myself, we want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association 2023. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.
Vidcast: https://youtu.be/nsq6RTRCqbk Here are the quickie reports about cutting edge medical and healthcare discoveries this 1st Week of August, 2022. Neuroblastoma, the development of cancer in the involuntary nervous system, is a deadly disease for children 5 years and younger. Now a group of biologists at Virginia Commonwealth University have identified a compound called SHP099 that blocks the enzymatic activation of the MEK/ERK proteins that potentiate the growth of these tumors. The best news is that even high doses of SHP099 have little effect on normal cells. The compound shrinks neuroblastoma tumors in mice and, hopefully someday, will also do so in children. https://bit.ly/3PNhduj MIT mechanical bioengineers have developed a wearable sticker capable of providing continuous, live ultrasound images. These stamp-sized devices mate arrays of ultrasound transducers with adhesives and capably create images of underlying organs for up to 48 hours. Currently, the patches must be wired to the imaging processors but, in the future, wireless versions may transmit to mobile processors to permit continuous ultrasound monitoring of body organs and developing babies. https://www.science.org/doi/10.1126/science.abo2542 Those awaiting heart transplants often need a boost in the pumping function provided by their own flagging hearts. Traditionally, that requires an implantable pump, a so-called left ventricular assist device, to be surgically inserted into the left ventricle during an open heart procedure. The Mayo Clinic now offers another option, a heart pumping a catheter called the Impella 5.5 that is non-invasively introduced into the heart via an armpit vessel. The device pumps blood out of the left ventricle into the aorta taking the load off the heart muscle. An added bonus: having this catheter pump pushes a transplant candidate higher up on the list. https://www.mayoclinic.org/medical-professionals/transplant-medicine/news/mayo-clinic-in-florida-first-hospital-in-the-world-to-use-a-new-heart-pump-as-bridge-to-transplant/mac-20519622 A prickly skin patch not only delivers CoVid vaccine without the dreaded hypodermic syringe feared by the needle-phobic, but it also triggers a higher level of CoVid protection. Australian researchers report that a protein-subunit CoVid vaccine triggers 11 fold higher levels of neutralizing antibodies against the Omicron variant when administered via a high density needle microarray patch compared with a conventional intradermal needle injection. https://www.sciencedirect.com/science/article/pii/S0264410X2200888X?via%3Dihub There you have the latest health reveals for this 1st Week of August, 2022, 2022. When additional information about these developments becomes available, I'll pass it on to you. #neuroblastoma #mekerk #shp099 #ultrasound #sticker #impella #lvad #CoVid #omicron #microarray
It's another session of CardioNerds Rounds! In these rounds, Co-Chair, Dr. Karan Desai (previous FIT at the University of Maryland Medical Center, and now faculty at Johns Hopkins) joins Dr. Ryan Tedford (Professor of Medicine and Chief of Heart Failure and Medical Directory of Cardiac Transplantation at the Medical University of South Carolina in Charleston, SC) to discuss the nuances of managing pulmonary hypertension in the setting of left-sided heart disease. Dr. Tedford is an internationally-recognized clinical researcher, educator, clinician and mentor, with research focuses that include the hemodynamic assessment of the right ventricle and its interaction with the pulmonary circulation and left heart. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes. Speaker disclosures: None Cases discussed and Show Notes • References • Production Team CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Challenging Cases - Nuances in Pulmonary Hypertension Management with Dr. Ryan Tedford Case #1 Synopsis: A woman in her late 30s presented to the hospital with 4 weeks of worsening dyspnea. Her history includes dilated non-ischemic cardiomyopathy diagnosed in the setting of a VT arrest around 10 years prior. Over the past 10 years she has been on guideline-directed medical therapy with symptoms that had been relatively controlled (characterized as NYHA Class II), but without objective improvement in her LV dimensions or ejection fraction (LVEF 15-20% by TTE and CMR and LVIDd at 6.8 cm). Over the past few months she had been noting decreased exercise tolerance, worsening orthopnea, and episodes of symptomatic hypotension at home. When she arrived to the hospital, she presented with BP 95/70 mmHg, increased respiratory effort, congestion and an overall profile consistent with SCAI Stage C-HF shock. In the case, we go through the hemodynamics at various points during her hospitalization and discuss options for management including medical therapy and mechanical support. The patient was eventually bridged to transplant with an Impella 5.5. Initial Hemodynamics Right Atrium (RA) Pressure Tracing: Right Ventricle (RV) Pressure Tracing: Pulmonary Artery (PA) Pressure Tracing: Pulmonary Capillary Wedge Pressure (PCWP) Tracing: Case 1 Rounding Pearls One of the first points that Dr. Tedford made was thinking about our classic frameworks of characterizing acute decompensated heart failure, specifically the “Stevenson” classification developed by Dr. Lynne Stevenson that phenotypes patients along two axes: congestion (wet or dry) and perfusion (warm or cold). Dr. Tedford cautioned that young patients may not fit into these classic boxes well, and that a normal lactate should not re-assure the clinician that perfusion is normal.In reviewing the waveforms, Dr. Tedford took a moment to note that besides just recording the absolute values of the pressures transduced in each chamber or vessel, it is critical to understand the morphology of the tracings themselves. For instance, with the RA pressure tracing above, there is no respiratory variation in the mean pressure. This is essentially a “resting Kussmaul's sign,” which is typically indicative of significant RV dysfunction. Thus, even though our echocardiogram in this case did not necessarily show a significantly dilated RV with mildly reduced longitudinal function (T...
It is our mission to provide patients with the highest level of care and access to cutting-edge, evidence-based technology and procedures. In this episode of “Heart to Heart,” we sit down with Dr. Trey Baucum and Mr. Richard Feinberg, who presented to the ER in very critical condition. Dr. Baucum had to make a quick and bold decision that ultimately led to a positive outcome for Mr. Feinberg. Listen to this episode to learn about Mr. Feinberg's story.
Please join author Mohamed Abdel-Wahab and Associate Editor Stefan James as they discuss the article "Comparison of a Pure Plug-Based Versus a Primary Suture-Based Vascular Closure Device Strategy for Transfemoral Transcatheter Aortic Valve Replacement: The CHOICE-CLOSURE Randomized Clinical Trial." Dr. Carolyn Lam: Welcome to Circulation on the Run. Your weekly podcast summary and backstage pass to the Journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature, a very interesting topic, looking at closure devices at the sites of access for patients that are undergoing TAVR procedures. But before we get to that, how about if we grab a cup of coffee and start with some of the other articles in the issue. Would you like to go first? Dr. Carolyn Lam: I would love to and I would like to describe not just one, but two articles from recent SGLT2 inhibitor trials. So, the first paper is an analysis of the DAPA-HF trial. Now we know that circulating high sensitivity, cardiac troponin T predominantly reflects myocardial injury. And higher levels are associated with a higher risk of worsening heart failure and death in patients with heart failure with reduced ejection fraction or HFrEF. But what about the prognostic significance of changes in high sensitivity troponin T over time and the effects of Dapagliflozin and on clinical outcomes in relation to baseline levels, as well as the effect of dapagliflozin on the high sensitivity troponin T levels? Well, this is what this study answers. It's a biomarker substudy of the DAPA-HF trial from Dr. Berg of the TIMI study group at Brigham women's hospital and colleagues. Dr. Greg Hundley: Wow. Carolyn, very interesting. So remind us about the DAPA heart failure trial. What was it about? Dr. Carolyn Lam: Ah, well, DAPA-HF was a randomized double blind placebo control trial of dapagliflozin in patients with symptomatic HFrEF defined by injection fraction 40% or less wherein dapagliflozin significantly reduced the primary endpoint of cardiovascular death or worsening heart failure events. And in today's biomarker substudy increases in high sensitivity, cardiac troponin T over a one year interval of time were highly predictive of subsequent risk of worsening heart failure and cardiovascular death. The effect of dapagliflozin on the primary endpoint was consistent irrespective of baseline troponin T concentration with no evidence of attenuated treatment benefit in those with very high troponin T concentrations. Dr. Greg Hundley: Very interesting Carolyn. Now you've got another study. Is this one on EMPA? Dr. Carolyn Lam: You are right. Thank you. The next paper is and analysis of the Emperor-Preserved trial. As a reminder, Emperor-preserved study the SGLT2 inhibitor empagliflozin in patients with HFpEF this time, which is a left ventricular ejection fraction above 40, and showed a significant reduction in the risk of cardiovascular death or heart failure hospitalization. The current paper evaluated the efficacy of empagliflozin on health related quality of life in patients with HFpEF and whether the clinical benefit observed with empagliflozin varied according to baseline health status. Dr. Greg Hundley: Very nice, super review Carolyn. So what were the results of this study? Dr. Carolyn Lam: In Emperor-Preserved, baseline health status and quality of life did not influence the magnitude of effect of empagliflozin on the risk of cardiovascular death or hospitalization for heart failure. Empagliflozin improved health status and quality of life as assessed by the Kansas city cardiomyopathy questionnaire across all domains and at all measured time points. Thus an effect that appeared early and was sustained for at least one year. Dr. Greg Hundley: Very nice. So two really informative papers on SGLT2 inhibitors. Well Carolyn, I'm going to turn the conversation to the world of preclinical science and talk about Titin. So Carolyn, titin truncation variants are the most common inheritable risk factor for dilated cardiomyopathy and their pathogenicity has been associated with structural localization. The A-band variants with overlapping myosin heavy chain binding domains appear more pathogenic than the I-band variants and the mechanisms for this are not well understood. So these investigators led by Dr. Hinson at the Jackson Laboratory for genomic medicine, performed a study demonstrating why A-Band variants are highly pathogenic for dilated cardiomyopathy and how they could reveal new insights into dilated cardiomyopathy pathogenesis. Titin functions and therapeutic targets were assessed. Dr. Carolyn Lam: Wow, interesting. So what did they enroll in? How did they do this? what did they find? Dr. Greg Hundley: Great Carolyn, so human Cardiomyocytes and cardiac micro tissue functional assays revealed that highly pathogenic A-Band Titin truncation mutations generate four shortened titin poisoned peptides and diminish full length, titin protein levels. While less pathogenic I-band titin mutations only diminish titin protein levels. And so Carolyn, the authors developed a one and done, genome editing therapeutic approach using CRISPR technology to repair the reading frame of Titin truncation mutations in cardiomyocytes. And therefore these genome editing therapeutics could correct the underlying genetic lesion responsible for dilated cardiomyopathy due to these Titin mutations. Dr. Carolyn Lam: Wow. Interesting. One and done genome editing. You learn something new every day with circulation. You've got another paper? Dr. Greg Hundley: Yes, Carolyn. Thank you. And so this paper comes to us from Dr. Beiyan Zhou From the Yukon health, school of medicine and again, from the world of preclinical science. So Carolyn, while several interventions can effectively lower lipid levels and people at risk for atherosclerotic cardiovascular disease, cardiovascular event risks remain, suggesting an unmet medical need to identify factors contributing to this cardiovascular event risk. Now monocytes and macrophages play central roles in atherosclerosis, but previous work has yet to provide a detailed view of macrophage populations involved in increased atherosclerotic cardiovascular disease risk. Dr. Carolyn Lam: Huh? Okay. Well, I'm super excited to hear what these investigators did Greg. Dr. Greg Hundley: Right, Carolyn. Well these authors developed a novel computational program. They call AtheroSpectrum, which identified a specific gene expression profile associated with inflammatory macrophage foam cells. And additionally, a subset of 30 genes expressed in circulating monocytes jointly contributed to the prediction of symptomatic atherosclerotic vascular disease. So therefore Carolyn, in the future, perhaps incorporating this new pathogenic foaming gene set with known risk factors may significantly strengthen the power to predict atherosclerotic cardiovascular disease risk. Dr. Carolyn Lam: Wow. Super interesting and well summarized. Thank you, Greg. Well also in today's issue, there's a Perspective by Dr. Kirtane on “The Long-Awaited Revascularization Guidelines are Out. What's In Them?” A Research Letter by Dr. Laffin on rise in blood pressure observed among us adults during the COVID 19 pandemic. Dr. Greg Hundley: Very Nice Carolyn. Well in our Cardiovascular News Segment, there's a piece on metabolic risk factors and how they drive the burden of Ischemic heart disease. Well, what a great issue here and now, how about we get onto that feature discussion? Dr. Carolyn Lam: Very Cool. Closure devices after TAVR. Here we go. Dr. Greg Hundley: Well, listeners welcome today to our feature discussion and we have with us Dr. Mohamed Abdel Wahab from Leipzig Germany. And we are going to discuss some issues pertaining to transcatheter aortic valve replacement, in terms of access to the arteries in the lower extremity. Welcome Mohamed. And can you start with, what was some of the background that led you to perform your study and what was the hypothesis that you wanted to address? Dr. Mohamed Abdel-Wahab: Thank you, Greg. And thank you for having me here. So as you mentioned, there are several cardiovascular procedures that currently require large-bore arterial access. The most common of these procedures is transcatheter aortic valve replacement. But there are other procedures as well, like endovascular aortic repair, mechanical circulatory devices. All of these require large-bore arterial access and of course, closure afterwards. And what we were interested in looking at was whether different types of vascular access site closure devices or strategies behave differently in the setting. Particularly in the setting of transcatheter aortic valve replacement. The reason behind this is that for many years, we only had one technique, to percutaneously close arterial access sites after these procedures. And these were mainly based on suture based devices or suture based techniques. Very recently, alternative techniques based on collagen plugs have been introduced. Dr. Mohamed Abdel-Wahab: And we know these types of devices or closure techniques from usual coronary intervention procedures for smaller access sites or for smaller sheath size. But they have been developed a step further for these large-bore procedures. These newer devices, particularly what we call the MANTA device, which is based on the collagen plug has been shown in initial visibility studies and also in registry based analysis to be very safe and effective. It leads to a very rapid hemostasis. And data from observational studies have suggested that it may be even superior to the suture based techniques, largely based on what we call the ProGlide device or the [inaudible 00:10:56]. And this is actually what we were aiming to look at. To compare these two different strategies based on two different devices. The suture based, the classical suture based technique using two ProGlides compared to the newer plug based technique using the MANTA in a population treated with TAVR. Dr. Greg Hundley: Very nice. And describe for us, your study design. And then also maybe explain a little bit more about the study population. Who did you include in this study? Dr. Mohamed Abdel-Wahab: So the design was more or less, very inclusive. So we designed the trial to more or less represent real word population. More or less [inaudible 00:11:40] population receiving transcatheter aortic valve replacement. So we included patients, of course where the procedure is being thought to be indicated and feasible by a multidisciplinary heart team. And also where the heart team thought that the transfemoral access route, which is the main route for the majority of patients, is obtainable and use of a percutaneous closure device is also possible. Dr. Mohamed Abdel-Wahab: Of course we had some exclusions. For example, patients where the use of a surgical access technique was necessary. They couldn't be naturally included in the trial. Patient that already had complications related, for example, to previous coronary angiogram PCI at the access site, they couldn't be included. But we were more or less, very inclusive in this trial. The trial population reflects the patients that are currently being treated with TAVR, so more or less an elderly population. More or less equally split-by males and females, which is very particular, again to the TAVR population. So this is a little bit different than the population that receives PCI, where we usually have a predominantly male population. This is not the case here. So these are the broad lines. Also reflecting current practice, the population that has been included in the trial is more or less overall, an intermediate risk population, when you look at the surgical scores. Dr. Greg Hundley: Very nice. So this was multicenter and then also patients were randomized to each of the two therapies, I believe. And was that a one to one randomization? Dr. Mohamed Abdel-Wahab: Exactly. So it was a multicenter trial. Patients were randomized between these two techniques. We mentioned the ProGlide based and the MANTA based in 1:1 fashion. And steering committee of course was more or less dominated by interventional cardiologists. Of course, in the context of this particular trial setting, the trial was only performed in Germany and it was an investigative initiated trial, not sponsored by the industry. Dr. Greg Hundley: Very nice. And can you describe for us, Mohamed, your results? Dr. Mohamed Abdel-Wahab: Yes. We actually hypothesized based on the observational data we have, that we will have less vascular complications with the MANTA based technique or the collagen based technique. At the end of the day, what we observed is completely the opposite. So the primary endpoint of the trial, which was what we call major and minor vascular complications defined according to the standardized criteria provided by the valve academic research consortium. These events occurred significantly more common in patients that were randomized to the MANTA based technique, as opposed to the ProGlide based technique, which was statistically significant. Dr. Greg Hundley: And did you observe those results across both the men and the women? And also, were there any differences in the results related to participants' age? Dr. Mohamed Abdel-Wahab: Yeah. So there were no interactions with various subgroups, both the predefined ones, including age and sex, as you mentioned. But also we looked at some post hoc subgroups, including for example, whether this is being affected by the size of the access vessels or by the presence and location of calcification, for example. But there were no interactions in all subgroups we looked at, with one exception which was chronic renal insufficiency. But all other subgroups showed actually no significant interaction, favoring the suture based, ProGlide based technique in all subgroups. Dr. Greg Hundley: Very good. And so can you describe in terms of, for individuals performing TAVR procedures and obtaining access, how do we use the results of your study to inform how we might move forward with closure of the artery in the future? Dr. Mohamed Abdel-Wahab: I mean, the first thing I would like to stress is the importance of doing randomized trials in general. Because I think this is not the first time we see opposite results when we are comparing randomized evidence with the evidence from observation studies, with the known limitations of observational comparative analysis. The second thing I think is really reassuring that the suture based technique that we know and that we have been using for many years now is safe and appears to be even more effective than the newly developed plug based technique. So this is one important information I think from this trial. The third piece of information is that the recently developed plug based technique, although being inferior in the study, it still may have some advantages in selected patients. And this is what we probably need to look at in a little bit more details in the future. Dr. Mohamed Abdel-Wahab: For example, what we realized from the study is that it could be a good option as a bailout device. So in some cases where the suture based technique has failed in the study, the crossover to the MANTA device was successful in the majority of cases. And may lead or help avoid complex endovascular interventions and implanting for example, stents or covered stents or even doing surgery. So this is something that is a nice observation from the dataset we have, but of course needs validation in larger studies. Dr. Greg Hundley: Very nice. And so really you've answered, kind of one of our key questions is, your thoughts on the next study that you see needs to be performed really in this area of research? Dr. Mohamed Abdel-Wahab: Yeah, so I think there are several things. One thing is, again, to look at potential patient subgroups that may benefit from the plug based device from the beginning. So probably it's not something that we should be using as a default strategy based on the results of this trial. But there could be certain subgroups we need maybe to dig a little bit more into the details or subgroups, if you wish to say so. Look a little bit more granularly at some patient groups that could benefit. But as mentioned, I think that the bailout indication is a very interesting one and needs to be looked at. Dr. Mohamed Abdel-Wahab: Not only in the TAVR setting, but also in the setting of other procedures. Such as for example, the use of mechanical circulatory assist device or ECMOs, where it may be difficult to apply these sutures post hoc. So the sutures that we apply during a TAVR procedure and what we use in this trial, this is the so-called preclosure technique. So you apply the sutures after gaining access. Then you insert your large-bore sheaths through the procedure. And then the sutures are already there and you can close the access site, usually without problems. Which is difficult, if you obtain access, for example, with an ECMO or an Impella. And then after a couple of days, you need to close it. So the sutures are not yet in place. In this particular scenario, it may be beneficial to use a plug afterwards. Or as a bailout device as previously Mentioned. Dr. Greg Hundley: Very nice well listeners. We want to thank Dr. Mohamed Abdel Wahab from Leipzig Germany for bringing us this study indicating that among patients treated with transfemoral TAVR, this pure plug based vascular closure technique using the MANTA VCD was associated with a higher rate of access site or access related vascular complications. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. Dr. Greg Hundley: This program is copyright of the American heart association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American heart association. For more, please visit AHA journals dot org.
CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Jaya Kanduri, Dr. Dan Lu, and Dr. Joe Wang from Weill Cornell Cardiology for Levain cookies in Central Park. The ECPR is provided by Dr. Harsimran Singh (Cardiology Program Director and Interventional Cardiologist with expertise in ACHD). We discuss a case of a 24-year-old female with a history of unicuspid aortic valve with associated aortopathy status post mechanical aortic valve replacement and Bentall procedure at age 16 presents with acute onset substernal chest pain and shortness of breath. She was found to have mechanical aortic valve obstruction and severe aortic regurgitation resulting in cardiogenic shock. Unfortunately, the shock quickly progressed to refractory cardiac arrest requiring mechanical support with VA-ECMO before valve debridement was performed in the operating room. The differential for mechanical prosthetic valve stenosis includes pannus, thrombus, or vegetation. She was eventually found to have thrombus obstructing the outflow tract and holding the mechanical leaflets open leading to torrential regurgitation. She underwent successful surgical debridement. We discuss unicuspid aortic valve and associated aortopathy, surgical considerations regarding AVR, diagnosis and management of prosthetic valve dysfunction, approach to cardiogenic shock and considerations around activating and managing VA-ECMO. With this episode, the CardioNerds family warmly welcomes Weill Cornell Cardiology to the CardioNerds Healy Honor Roll. The CardioNerds Healy Honor Roll programs support and foster the the CardioNerds spirit and mission of democratizing cardiovascular education. Healy Honor Roll programs nominate fellows from their program who are highly motivated and are passionate about medical education. The Weill Cornell fellowship program director, Dr. Harsimran Singh has nominated Dr. Jaya Kanduri for this position. Claim free CME just for enjoying this episode! Disclosures: NoneJump to: Pearls - Notes - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Media ECGCXREchoRHC PSL AP3 Color LHC - LCA LHC - LCA RCA Aortogram TEE TEE 2 Episode Teaching Pearls - Mechanical Valve Thrombosis (1) Unicuspid aortic valves present with aortic stenosis earlier in life. There can be concurrent aortic regurgitation and, like bicuspid aortic valves, unicuspids can be associated with aortopathy as well as other congenital anomalies. (2) Prosthetic valve stenosis is assessed with different echocardiographic parameters than what we use for native valves. The differential for mechanical valve stenosis includes pannus, thrombus, or vegetation. Patient prosthesis mismatch may also lead to elevated gradients. (3) VA-ECMO provides robust flow in the setting of cardiogenic shock as well as gas exchange. While this flow may improve end-organ perfusion, it also increases left ventricular afterload, thereby potentially worsening LV ischemia and impeding LV recovery. Elevated afterload may also decrease innate contractility and prevent aortic valve leaflets from opening. Therefore, if a patient with a mechanical valve is on VA-ECMO, ensuring valve opening to prevent valve (or ventricular) thrombosis is paramount. (4) Venting is sometimes necessary to decrease the left ventricular end diastolic pressure from the high afterload imposed by VA-ECMO. A microaxial temporary LVAD (example – Impella device) directly unloads the left ventricle, but cannot be used in the setting of a mechanical aortic valve. TandemHeart is also a consideration (inflow cannula placed across the interatrial septum in the left atrium) to unload the LV, but does not improve flow across the aortic valve so can lead to thrombus if a...
John Ingram, CCP discusses the Impella 5.5 with SmartAssist Heart Pump Technology by ABIOMED.
From CodaZero Live, Steve Morgan talks to us about temporary mechanical circulatory support in cardiogenic shock. Steve gives an example of a patient with refractory cardiogenic shock, who hasn't responded to pharmacological support. So, how do we go about choosing between temporary circulatory support options? First, Steve acknowledges that critical care echocardiography is central. Additionally, he discusses the use of pulmonary artery catheters. Finally, Steve hopes that future Randomised Control Trials might contribute to a better evidence base to guide the use of these supports in specific patients. Finally, for more, head to our podcast page #CodaPodcast
In today's episode, we discuss almost everything you could want to know about intra-aortic balloon pumps with special guest, Dr Ivan Rapchuk. In this episode, we focus on the physiology of how the pumps work to improve cardiac function. Feel free to email us at deepbreathspod@gmail.com if you have any questions, comments or suggestions. We love hearing from you!Thanks for listening, and happy studying.Resources for today's episode: Principles of intra-aortic balloon pump counterpulsation by M. Krishna and K. Zacharowski. https://academic.oup.com/bjaed/article/9/1/24/466259 The normal IABP waveform: https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%206.3.4/normal-iabp-waveform The abnormal IABP waveform: https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%206.3.4.2/pathophysiology-abnormal-iabp-arterial-waveforms The Impella Device: historical background, clinical applications and future directions by J. Glazier and A. Kaki. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679960/ Youtube video illustrating how an Impella works: https://www.youtube.com/watch?v=GhWB7T5QxMI
In today's episode, we discuss almost everything you could want to know about intra-aortic balloon pumps with special guest, Dr Ivan Rapchuk. In part 2 of this series, we talk about which patients benefit most from balloon pumps, optimal and suboptimal balloon timing, and those things to be mindful of when anaesthetising a patient with a balloon pump in situ. Lastly, we have a brief chat about the similarities and differences between intra-aortic balloon pumps and the newer Impella devices. Feel free to email us at deepbreathspod@gmail.com if you have any questions, comments or suggestions. We love hearing from you!Thanks for listening, and happy studying.Resources for today's episode: Principles of intra-aortic balloon pump counterpulsation by M. Krishna and K. Zacharowski. https://academic.oup.com/bjaed/article/9/1/24/466259 The normal IABP waveform: https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%206.3.4/normal-iabp-waveform The abnormal IABP waveform: https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%206.3.4.2/pathophysiology-abnormal-iabp-arterial-waveforms The Impella Device: historical background, clinical applications and future directions by J. Glazier and A. Kaki. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679960/ Youtube video illustrating how an Impella works: https://www.youtube.com/watch?v=GhWB7T5QxMI
Cardiothoracic Surgeon Dr. Randall Buss, describes the use of two life-saving devices in heart surgery. Click here for a transcript of this episode!
Paul J. Wang: Welcome to the monthly podcast, On the Beat for Circulation: Arrhythmia and Electrophysiology. I'm Dr. Paul Wang, Editor-in-Chief, with some of the key highlights from this month's issue. In our first paper, Bruce Wilkoff and associates examine the impact of cardiac implantable electronic device [CIED] infections on mortality, quality of life, healthcare utilization, and cost in the U.S. Healthcare system. They found that the majority CIED infection was associated with increased all-cause mortality, 12-month risk-adjusted hazard ratio 3.41, P < 0.001. An effect that sustained beyond 12 months. The quality of life was reduced, P = 0.004, and did not normalize for six months. Disruptions in CIED therapy were observed in 36% of infections for a median duration of 184 days. The authors reported that the mean hospital costs were $55,547. In our next paper, Songwen Chen, Xiaofeng Lu and associates examine the ability to eliminate premature ventricular complexes [PVCs] originating from the proximal left anterior fascicle, safely from the right coronary sinus. The authors mapped the the right coronary sinus and left ventricle in 20 patients with left anterior fascicle PVCs. They found that the earliest activation site with Purkinje potential during both PVC and sinus rhythm was localized at proximal left anterior fascicle in eight patients, the proximal group, or non-proximal left anterior fascicle in 12 groups, the non-proximal group. The Purkinje potentials proceeded PVC-QRS at the earliest activation site in proximal group 32.6 milliseconds was significantly earlier than that in non-proximal group, 28.3 milliseconds P = 0.025. Similar difference in the Purkinje potentials proceeding sinus QRS at the earliest activation site was also observed between proximal and non-proximal group, 35.1 milliseconds versus 25.2 milliseconds, P < 0.001. In proximal group, the distance between the earliest activation site to the left His-bundle into the right coronary sinus were shorter than that of the non-proximal group 12.3 millimeters versus 19.7, P = 0.002, and 3.9 millimeters versus 15.7 millimeters, P < 0.001, respectively. The authors found no difference in the distance between the right coronary sinus to proximal left anterior fascicle between the two groups. PVCs were successfully eliminated from the right coronary sinus in all proximal group, but at left ventricular earliest activation site for the non-proximal group, the radiofrequency application time, ablation time and procedure time of non-proximal group were longer than that proximal group. Electrocardiographic analysis showed that when compared to non-proximal group, the PVCs proximal group had a narrower QRS duration, smaller S wave in leads one, V five,and V six; lower R waves in leads one, aVL, aVR, V one, V two, and V four and smaller q wave in leads three and aVF. The QRS duration difference [PVC-QRS and sinus rhythm QRS] < 15 milliseconds predicted the proximal left anterior fascicle origin with high sensitivity and specificity. In our next paper, Benjamin Steinberg and associates examined the factors that are associated with large improvements in health-related quality of life in patients with atrial fibrillation. The authors assessed factors associated with a one-year increase in quality of life, measured by AFEQT of one standard deviation that is greater and equal to 18 points, three times clinically important difference among patients in the ORBIT-AF one registry. They found that 28% of patients had such a health-related quality improvement compared with patients not showing large health-related quality of life improvement. They were similar age, (median 73 versus 74 years of age), equally likely to be female, (44% versus 48%), but more likely to have newly diagnosed atrial fibrillation [AF] at baseline (18% versus 8%, P = 0.0004) prior antiarrhythmic drug use (52% versus 40%, P = 0.005), baseline antiarrhythmic drug use (34.8% versus 26.8%, P = 0.045), and more likely to undergo AF related procedures during follow-up (AF ablation 6.6% versus 2.0%, cardioversion 12.2% versus 5.9%). In multivariate analysis, a history of alcohol abuse has a ratio 2.4 and increased baseline diastolic blood pressure has a ratio 1.23 per 10 point increase and greater than 65 millimeters of mercury were associated with large improvements in health-related quality of life at one year. Whereas patients with prior stroke, chronic obstructive pulmonary disease and peripheral artery disease were less likely to improve. In our next paper, Eiichi Watanabe and associates studied safety and resource consumption of exclusive remote follow-up in pacemaker patients for two years. Consecutive pacemaker patients committed to remote pacemaker management were randomized to either remote follow-up or conventional in-office follow-up at twice yearly intervals. Remote follow-up patients were only seen if indicated by remote monitoring, all returned to hospital after two years. In 1,274 randomized patients (50.4% female, age 77 years), 558 remote follow-up or 550 conventional in office follow-up patients reached either the primary end point or 24 months follow-up. The primary end point, a composite of death, stroke, or cardiovascular events requiring surgery occurred in 10.9% and 11.8% respectively in the two groups (P = 0.0012) for non-inferiority. The median number of in-office follow-ups was 0.5 in the remote follow-up group and 2.01 in the conventional in-office follow-up per patient year (P < 0.001). Only 1.4% of remote follow-ups triggered an unscheduled in-office follow-up, and only 1.5% of scheduled in-office follow-ups were considered actionable. In our next paper, Sarah Strand and associates use fetal magnetocardiography from the University of Wisconsin biomagnetism laboratory to study 39 fetuses with pathogenic variants in long QT syndrome, LQTS genes. 27 carried the family variant, 11 had de novo variants, and one was indeterminant. De novo variants, especially de novo SCN5A variants were strongly associated with a severe rhythm phenotype and perinatal death. Nine or 82% showed signature LQTS rhythms, six showed torsade de pointes, five were still born, and 9% died in infancy. Those that died exhibited novel fetus rythms, including AV block with 3:1 conduction ratio, QRS alternans in 2:1 AV block, long cycle length, torsade de pointes, and slow monomorphic ventricular tachycardia. Premature ventricular contractions were also strongly associated with torsade de pointes and perinatal death. Fetuses with familiar variants showed a lower incidence of signature LQTS rhythm, six out of 27 or 22%, including torsade de pointes, and 3 out of 27 or 11% all were live born. The authors concluded that the malignancy of de novo LQTS variants was remarkably high and demonstrate that these mutations are a significant cause of stillbirth. In our next paper, Corina Schram-Serban and associates compare the severity of extensiveness of conduction disorders between obese patients and non-obese patients measured at high resolution scale. They studied 212 patients undergoing cardiac surgery (male:161, mean 63 years of age), who underwent epicardial mapping of the right atrium, Bachmann's bundle, and left atrium during sinus rhythm. Conduction delay [CD] was defined as interelectrode conduction time seven to 11 milliseconds and conduction block [CB] as conduction time ≥ 12 milliseconds. In obese patients, the overall incidence of conduction delay was 3.1% versus 2.6% (P = 0.002), conduction block 1.8% versus 1.2%, and continuous CDCB 2.6% versus 1.9% higher in the obese patients, conduction delay (P = 0.012) and continuous CDCB lines are longer. There were more conduction disorders at Bachman's bundle, and this area has a higher incidence of conduction delay 4.4% versus 3.3% (P = 0.002), conduction block 3.1% versus 1.6% (P < 0.001), continuous conduction block conduction delay 4.6% versus 2.7% and longer conduction delay or conduction delay conduction block lines. Severity of conduction block is also higher, particularly in the Bachmann bundle and pulmonary vein areas. In addition, obese patients have a higher incidence of early de novo postoperative atrial fibrillation. Body mass index and the overall amount of conduction block were independent predictors for the incidents of early postoperative atrial fibrillation. In our next paper, Ricardo Cardona-Guarache and associates describe five patients with concealed, left-sided nodoventricular in four patients and nodofascicular in one patient accessory pathways. They proved the participation of accessory pathway in tachycardia by delivering His-synchronous premature ventricular complexes that either delayed the subsequent atrial electrogram or terminated the tachycardia, and by observing an increase in ventricular atrial interval coincident with left bundle branch block in two patients. The accessory pathways were not atrioventricular pathways because the septal ventricular atrial interval during tachycardia was less than 70 milliseconds in 3, 1 had spontaneous AV dissociation, and in 1 the atria were dissociated from the circuit with atrial overdrive pacing. Entrainment from the right ventricle showed ventricular fusion in 4 out of 5 cases. A left-sided origin of accessory pathways was suspected after failed ablation of the right inferior extension of the AV node in 3 cases and by observing VA increase in left bundle branch block in 2 cases. The nodofascicular in 3 of the 4 nodoventricular accessory pathways were successfully ablated from within the proximal coronary sinus guided by recorded potentials at the roof of the coronary sinus, and nodoventricular accessory pathway was ablated via a transseptal approach near the coronary sinus os. In our next paper, Pierre Qian and associates examined whether an open irrigated microwave catheter ablation can achieve deep myocardial lesions endocardially and epicardially through fat while acutely sparing nearby coronary arteries. Epicardial ablations via subxiphoid access in pigs were performed at 90 to 100 Watts at four minutes at sites near coronary arteries and produced mean lesion depth of 10 millimeters, width 18 millimeters, and length 29 millimeters through median epicardial fat thickness of 1.2 millimeters. Endocardial ablations at 180 Watts achieved depths of 10.7 millimeters, width of 16.6 millimeters, and length of 20 millimeters. Acute coronary occlusion or spasm was not observed at median separation distance of 2.7 millimeters. In our next paper, Jad Ballout and associates examined 21 consecutive patients with cardiogenic shock and refractory ventricular arrhythmias undergoing bailout ablation due to inability to wean off of mechanical support. Mean age was 61 years, 86% were males, median left ventricular injection fraction 20%, 81% ischemic cardiomyopathy. The type of mechanical support in place prior to the procedure was intra-aortic balloon pump in 14 patients, Impella in 2, ECMO in 2, ECMO and intra-aortic balloon pump in 2, and ECMO and Impella in 1. In the cardio voltage maps with myocardial scar in 90% (19 patients), the clinical ventricular tachycardias VTs were inducible in 13% (62 patients), whereas 6 patients had PVC induced ventricular fibrillation, VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 patients with inducible clinical VTs, substrate modification was performed in 15 patients with scar in 79%. After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully with the majority of patients being discharged home and surviving beyond one year. However, 6 (29%) died during the index admission with persistent cardiogenic shock. In a research letter, Parveen Garg and associates examined the multi-ethnic study of atherosclerosis [MESA] incident atrial fibrillation a population with 50% African-American or Hispanic. After adjusting for age, race, ethnicity, sex education, income, clinic site, height, body, mass index, cigarette, smoking, diabetes, systolic and diastolic blood pressure, and hypertensive medications, physical activity, alcohol consumption, lipid parameter to lipid lowering therapy, the baseline lipoprotein A level greater or equal to 30 milligram per deciliter was inversely associated with developing atrial fibrillation compared those with lower levels (hazard ratio 0.84). However, the mechanism of this paradoxical association is unclear. In another research letter, Yoshihide Takahashi and associates reported that 49 patients undergoing ablation of persistent atrial fibrillation had at least one focal site and rotational activation in 57%. Of these, 19 patients underwent a repeat ablation for recurrent atrial fibrillation. AF was mapped in 17 patients and 131 focal activation sites were ablated. There were 105 displayed focal activation sites during the de novo ablation and 89 focal activation sites during the repeat ablation. During the de novo ablation, rotation activation was observed in 19 sites. Of the 19 sites, 12 (63%) displayed rotational activity, also with the repeat ablation. The author suggested focal or rotational activation sites can be classified into two types, ones critical for AF recurrence and the ones that are bystander. That's it for this month. We hope that you'll find the journal to be the go-to place for everyone interested in the field. See you next time. This program is copyright American Heart Association, 2020. Correction: In the study by Pierre Qian and associates, the epicardial ablations via subxiphoid access were performed in sheep, not pigs, as previously stated.
This week's episode features author Torbjørn Omland and Senior Guest Editor Vera Bittner as they discuss the artile "Growth Differentiation Factor-15 Provides Prognostic Information Superior to Established Cardiovascular and Inflammatory Biomarkers in Unselected Patients Hospitalized with COVID-19." TRANSCRIPT BELOW: Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary, and backstage pass to the journal and its editors. We are your co-hosts, I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: I'm Dr. Greg Hundley, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn our feature this week gets into inflammatory biomarkers in patients that have been hospitalized with COVID-19, but before we get to that, how about we grab a cup of coffee and work through some of the papers in the issue. Would you like to go first? Dr. Carolyn Lam: Absolutely. With both the coffee and the papers. So great, for this first paper, have you thought about concentric versus eccentric cardiac hypertrophy? We traditionally associate them with pressure versus volume overload respectively in cardiovascular disease, both though conferring an increased risk of heart failure. These contrasting forms of hypertrophy are characterized by asymmetric growth of the cardiac myocytes in mainly width or length respectively. However, the molecular mechanisms determining myocyte preferential growth in width versus length remain poorly understood. Dr. Carolyn Lam: That is until today's paper, and it is from Dr. Kapiloff from Stanford University, and Dr. Rosenfeld from UCSD, School of Medicine and their colleagues, and what they did was used primary adult rat ventricular myocytes, as well as Adeno associated virus mediated gene delivery in mice, to define a regulatory pathway controlling pathological myocyte hypertrophy, and they found that asymmetric cardiac myocyte hypertrophy is modulated by serum response factor phosphorylation, constituting an epigenomic switch balancing the growth in width versus length of adult ventricular myocytes In vitro, and In vivo. Dr. Carolyn Lam: Serum response factor phosphorylation was bi-directionally regulated at signalosomes organized by the scaffold protein muscle, A kinase anchoring protein beta. This newly identified molecular switch controlled a transcriptional program responsible for modulating changes in cardiomyocyte morphology that occurs secondary to pathological stressors. Dr. Greg Hundley: Very nice, Carolyn. So switches controlling this transcriptional program. Tell us a little bit, and bring us back to the clinical relevance of this and starting with that concentric versus eccentric hypertrophy? Dr. Carolyn Lam: I thought you may ask. The identification of a molecular mechanism regulating that asymmetric cardiomyocyte growth, really provides a new target for the inhibition of pathological cardiac hypertrophy. Studies in mice using these Adeno associated virus based gene therapies to modulate that signalosome, really provided proof of concept for translational potential in the treatment of pathological cardiac remodeling and prevention of heart failure. Dr. Greg Hundley: Oh, wow. Very nice, Carolyn. Well, my first paper comes to us from Professor Dirk Westermann from Hamburg, and focuses on cardiogenic shock patients, and veno-arterial ECMO, the results from the international multicenter cohort study. So Carolyn this study evaluated data from 686 consecutive patients with cardiogenic shock treated with VA ECMO with or without left ventricular unloading using an Impella, and they conducted this at 16 tertiary care centers across four countries. They examined the association between left ventricular unloading and 30 day mortality. Dr. Carolyn Lam: Huh, so what did they find? Dr. Greg Hundley: Okay. Carolyn. Well, left ventricular unloading was used in 337 of the 686 patients enrolled, and after propensity matching 255 patients with left ventricular unloading were compared with the 255 patients without left ventricular unloading. In the match cohort, left ventricular unloading was associated with lower 30 day mortality without differences in the various subgroups. However, complications occurred more frequently in patients with left ventricular unloading, like severe bleeding, which happened in 38.4% versus only 17.9% in those without unloading. There was also access-related ischemia and renal replacement therapy. Dr. Greg Hundley: So Carolyn, the take-home message from this International multi-center cohort study, is that left ventricular unloading is associated with lower mortality, and cardiogenic shock patients treated with VA ECMO, despite higher complication rates. In the absence of randomized trial data these findings support the use of left ventricular unloading and cardiogenic shock patients treated with VA ECMO, and call for further validation, ideally in a randomized controlled trial. Dr. Carolyn Lam: Very nice. Well for my next paper, Greg, it's all about desmin. Now we know that mutations in the human desmin gene caused myopathies and cardiomyopathies. Well, today's authors, Dr. Hermann and Schroeder from University Hospital Erlangen in Germany and Dr. Lilienbaum from University of Paris and France and their colleagues, report an adolescent patient who underwent cardiac transplantation, due to restrictive cardiomyopathy caused by a heterozygous R406W desmin mutation. Sections of the explanted heart were analyzed with antibodies specific to 406W-desmin, and to intercalated disc proteins. Effects of this mutation on the molecular properties of desmin were then addressed by cell transfection and In vitro assembly experiments. They further generated these desmin mutation knock-in mice haboring the orthologous form of the human, R406W-desmin. Dr. Greg Hundley: So Carolyn, what did they find? Dr. Carolyn Lam: Well, they demonstrated a novel pathomechanism in which cardiotoxic R406W-desmin, could adapt dual functional status with the abilities to integrate into the indogenous intermediate filament network, and to cause formation a protein aggregates. This R406W-desmin modified the extra sarcomeric cytoskeleton, such that desmin filaments were not anchored to desmosomes anymore. Thereby destroying the structural, and functional integrity of intercalated discs. Dr. Greg Hundley: What are the clinical implications? Dr. Carolyn Lam: Well, since these cardiotoxic desmin mutations could affect the integrity of intercalated discs, thereby inducing conduction defects and malignant arrhythmias, they suggest early implantation of pacemaker, or cardioverter defibrillator devices, may be considered to prevent certain cardiac death in patients with these mutations. Furthermore, state-of-the-art basic molecular risk stratification of desmin mutations may encompass a multidisciplinary experimental approach as exemplified by the approach taken here, which comprises assessment of the tissue pathology in conjunction with genome analysis and desmin assembly studies as well as patient mimicking cell and animal models for the In vivo validation of these mutations. Dr. Greg Hundley: Well, fantastic, Carolyn. Well, my next paper comes to us from Dr. Ravi Shah from the Massachusetts General Hospital. This study evaluated 2,330 white and black young adults, average age of 32 years, in the Coronary Artery Risk Development in Young Adults, or the cardiac study, to identify metabolite profiles associated with an adverse cardiovascular disease phenom that included, myocardial structure and function, fitness, vascular calcification, and then also mechanisms, and other cardiovascular outcomes that would occur over the next two decades. Statistical learning methods, including elastic nets and principal component analysis, and Cox regression generated parsimonious metabolite based risk scores, validated in over 1800 individuals in the Framingham Heart Study. Dr. Carolyn Lam: Wow. What did they show, Greg? Wow, that's a lot of work. Dr. Greg Hundley: Yeah. So Carolyn, the authors found two multiparametric metabolite-based scores linked independently to vascular, and myocardial health. With metabolites included in each score specifying microbial metabolism, hepatic steatosis, oxidative stress, nitric oxide modulation, and finally collagen metabolism. Over nearly 25 year median follow-up, and cardia, this metabolite based vascular score, and the myocardial score, and the third and fourth decade of life were associated with clinical cardiovascular disease. Importantly, the authors replicated these findings in 1,898 individuals in the Framingham Heart Study followed over two decades, such that young adults with poor metabolite based health scores had higher hazard ratios of future cardiovascular disease related events. Dr. Carolyn Lam: Oh wow. Greg, what an elegant study with both development and validation cohort evaluating the metabolome. Dr. Greg Hundley: Yes. Carolyn. So metabolic signatures of myocardial, and vascular health in young adulthood specify known novel pathways of metabolic dysfunction, relevant to cardiovascular disease associated with outcomes in two independent cohorts. So these data suggests that efforts to include precision measures of metabolic health in risk stratification to interrupt cardiovascular disease at an early at stage, are warranted. Dr. Carolyn Lam: Wow. So interesting. Other very interesting articles in today's issue, there's an In Depth article by Dr. Angiolillo entitled, “The Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients with Coronary Artery Disease and Diabetes.” There's also Research Letters, one by Dr. Sultan on, “The Longterm Outcomes of Primary Cardiac Lymphoma” and one by Dr. Wang on, “Loss of Phosphatase and Tensin Homolog Promotes Cardiomyocyte Proliferation and Cardiac Repair Following Myocardial Infarction.” Dr. Greg Hundley: Great, Carolyn. Well, I've got a couple other articles in this issue as well. One is by Professor Ganesan Karthikeyan who has an On My Mind piece entitled an “Alternative Hypothesis to explain Disease Progression in Rheumatic Heart Disease.” Dr. Stuart Chen has an ECG challenge entitled, “Alternating QRS Duration and a Normal T-waves. What is the mechanism?” Then finally, Carolyn, a series of Letters to the Editor, one by Dr. Peterzan and the other by Dr. Mehmood regarding the prior published article, entitled “Cardiac Energetics in Patients with Aortic Stenosis and Preserved Ejection Fraction.” Well, Carolyn, how about we get onto that feature article and learn more about inflammatory biomarkers in hospitalized patients with COVID-19? Dr. Carolyn Lam: Yes. Let's go. Greg. Biomarkers are really playing an increasingly important role in cardiovascular disease, and even in the current COVID 19 pandemic, there's been a lot of news about how biomarkers such as traponin may be prognostic, and in fact, we're all wondering about maybe even newer biomarkers. In fact, today's feature discussion does bring to light one of the newest, and in fact, this is the first publication on the role of Growth Differentiation Factor 15 or GDF-15 in COVID-19. We're so pleased to be discussing this with the corresponding author, Dr. Torbjørn Omland from University of Oslo, in Norway, as well as our senior guest editor, Dr. Vera Bittner from University of Alabama at Birmingham. So welcome both. Tobjorn, could you tell us a little bit about GDF-15 and what made you look at it, and what did you find? Dr. Torbjørn Omland: Yeah, so GDF-15, that's a very interesting biomarker. It's considered a biomarker of biological aging cellular stress, and perhaps also the inflammation, and tests being studied within the cardiovascular field for some years now, and it has been shown to be a strong prognostic indicator across the cardiovascular spectrum, actually. So it is a new biomarker in one sense, but there are some data already in the cardiovascular field. Dr. Carolyn Lam: Not in COVID. So this is the first study to really look at its prognostic value in COVID 19. So congratulations Torbjorn, and if I may also to the first author, Dr. Peter Meer, a good friend as well, but please, could you tell us about your study and what you found? Dr. Torbjørn Omland: Yes. So when the COVID pandemic hit Norway in the spring, we thought that we should plan a prospective biomarker study. So we had to really fast track approval by the IRB and so forth, and we're able to actually cover most of the patients that were hospitalized in our hospital, Akershus University hospital, which is right outside of Oslo, and it's a pretty large hospital by Norwegian standards. It covers about 11% of the Norwegian population. Dr. Torbjørn Omland: So in that period, when we were including, we had 136 patients hospitalized with confirmed COVID 19, and we have biobank bank samples from 123 of these, and then there have been reports from retrospective studies, first from China, that seemed to suggest that markers like cardiac troponin, Anti-Troponin T, and Ferritin were associated with outcome, but those studies were prone to selection bias in that the measurements were performed in the most sick patients. So in this study we included all patients and then we thought we should examine a broad panel of biomarkers, and that included Interleukin 6, CRP, Procalcitonin, Ferritin, and the D-dimer Cardiac troponin, and N-terminal pro B, and GDF-15. Dr. Carolyn Lam: Wow. Thank you, Torbjorn. Even before you carry on with the results, can I just say having visited your hospital in pre-COVID days, I can only imagine what a work of love this was to do it prospectively. Any particular experiences to talk about, to get a fast-track even in the midst of to perform a well done prospective study, that must have taken a lot. Dr. Torbjørn Omland: Yes. But it's also interesting in that the whole sort of ablation on Norway was very much into this from the highest political level. Also, the decision that the older research on COVID should be prepared to retire, then the IRB had an eight hour and deadline for them to approve or not approve the study. So that's went surprisingly smoothly, I must say. Dr. Carolyn Lam: Wow, that's great. So what did you find? Dr. Torbjørn Omland: Yeah, so we found that among these biomarkers, several seem to predict outcome, and the primary end point of this study was to combined end-point of the hospitalization in the ICU, or death. We found that also markers like cardio traponin, BNP, ferritin, and the D-dimer and so forth, in univariable analysis, were very associated with outcome, but when we perform a more comprehensive, mostly variable modeling, then the prognostic value of some of these markers disappeared. In contrast, for GDF-15, it seemed to perform very strongly, both on the baseline sample, and interestingly also it increased in those reaching the primary end-point during the hospitalization. So it provided a very strong and independent information also when we adjusted for clinical risk scores, like the NEWS score. So that was a very pleasant surprise to see that there was one marker that's actually performed so well. The other marker that's also performed well was Ferritin. Dr. Carolyn Lam: Very interesting, and so the new score being the National Early Warning Score. Thank you. Verra, I really love to bring in your thoughts. I mean, could you take us behind the scenes with the editors? What did you think when you saw this paper? Dr. Vera Bittner: As you know, I mean, a lot of journals have been inundated by COVID papers, and so this one stuck out to us, because it's the first time that we had seen that anybody linked GDF-15 to a COVID population, even though it has been out in the literature for ACS, and in my prognostication, and in a healthy populations, and in chronic coronary disease populations, heart failure, and so on. So this is the first time that we've seen it applied there. Dr. Vera Bittner: Then I would echo some of the things that Torbjorn said, that we were also impressed, that it was prospective, because when you look at some of the other biomarker studies, what was prognostic in one with then not shake out the other one, because either different variables were included in the models, because the population's differed. So to have something that was representative of the population that was actually admitted to this, Norwegian Academic Hospital, stood out to us. So we're excited to get this paper basically for circulation, and hope that it also will be impetus for future research. Dr. Carolyn Lam: Thank you so much for sharing that end for helping us publish such a beautiful paper. Did you have some questions for two of your own? Dr. Vera Bittner: Yeah. So what stuck out to me is that you had this a whole crew of biomarkers, and then when you looked ultimately at the final model, there were two that were standing out, that was ferritin, and it was the GDF-15, and then when I looked at your graph, it looks like not only did these biomarkers measure different contrasts, but their time-course also seemed to be different, and so I was just wondering whether you had thought about, maybe using these to joint the model outcome, and whether we might even be able to get more information that way. Dr. Torbjørn Omland: I think that's an excellent suggestion, and as you correctly pointed out, they do have different sort of profiles and ferritin being an acute phase reactant, having various sort of dramatic early rise whereas we see that GDF-15 increased progressively during the course of hospitalization in the most severe patients. I think when combining them, is actually a great IMT that we should look further into. Dr. Carolyn Lam: Very nice. Torbjorn, if I could, I've got a couple of questions too. So 123 patients, 35 of whom had the primary outcome, right? So that may be sort of seen as, is this too small? and they're all hospitalized patients. So could I ask, what do you predict maybe seen in a larger population or outside of Norway or in a non-hospitalized population? Dr. Torbjørn Omland: So as you say, we were early with this report, but since it was submitted, there has been a couple of smaller studies that seemed to confirm our results. So that is reassuring, but of course we would like to have studied this in logical patients. We are in touch with the other biobank samples that could possibly confirm the data. So that's one obvious step. Then it's very interesting, as you say, could we sort of expand this to also apply to non-hospitalized patients? I think that it would be a very interesting hypothesis to test, and I think there's still a pretty good rationale for this. Dr. Torbjørn Omland: It's interesting that the insoluble group actually showed a correlation that when the soluble ST2 concentrations and GDF-15. So there might be that those with more susceptibility to COVID infections, actually, I thought that, that is actually reflected by GDF-15 concentrations, but the challenge is how to sort of get a representative non-hospitalized population, but interestingly, I was approached by some of the hospital staff that actually are in contact with general practitioners, and wanted sort of implement this test also for this group. Dr. Carolyn Lam: So Verra, we're really grateful that Allan Jaffe was working with you in managing this beautiful paper, and if you don't mind me cheekily paraphrasing that you said you might channel him, if you could, what would the channeled Allan Jaffe perhaps say about what's needed in this whole biomarkers fear in COVID-19? Dr. Vera Bittner: Hopefully, many. A channeling element is obviously difficult, because he is such an incredible expert on biomarkers that I can't even pretend to be able to see, that you might be thinking, but it seems to me that one thing that we could all agree on is that it would be really exciting if something like the: get with the guidelines COVID registry, could decide to measure this marker perspectively in the participating hospitals, for example. Dr. Vera Bittner: Then be able to look at this in a much, much larger population. I mean, especially with different ethnic backgrounds as well. I mean, I noticed actually to my surprise that, this Norwegian study how to fairly high proportion of Asians in the sample, but that may not be the ethnic distribution that we might see in different regions of the US, or different regions of the world. So it would be really nice to incorporate the measurement of this biomarker in much larger datasets. So things can be explored a bit further. Dr. Carolyn Lam: That's excellent, and Torbjorn, if you could channel Allan. What would you say? Dr. Torbjørn Omland: That's a difficult path, but absolutely just to me what Verra said. Then I think the importance of prospective studies in the COVID biomarker field, I think is our at most importance. Dr. Carolyn Lam: I think on behalf of both Torbjorn and I, and in fact everyone in circulation. Thank you, Verra for the amazing work that you and your team do for circulation as well. Thank you so much for making the time to share your thoughts today and thank you for that beautiful, beautiful paper both of you. Thank you. (singing). Listeners you've been listening to Circulation on the Run. Thank you for joining us from Greg and I. Don't forget to tune in again next week. Dr. Greg Hundley: This program is copyright, the American Heart Association 2020.
Cardio thoracic surgeon Dr. Nishant Patel talks about the latest Impella device technology he is pioneering here in Palm Beach as well as the latest in bypass surgery. He also talks about the differences between cardiac disciplines that many of us find confusing at times. A simply wonderful guest and a show you don’t want to miss.
We discuss cardiogenic shock and decision making in the case of a young female presenting to the ER. We have a panel of cardiologists guide the discussion. Drs Rene Alvarez, Daniel Sims and Alec Vishnevski discuss the case presented by cardiology fellow Rachna Kataria, MD. Thanks for listening. Please like, subscribe and give us a rating.
In this week’s Parallax, host Ankur Kalra is joined by Charles (Chuck) Simonton, Vice President and Chief Medical Officer of Abiomed. Chuck talks about how his father’s leadership and service as a Methodist minister inspired him to become a doctor. He recalls the dawn of interventional cardiology: the birth of angioplasty and stenting. Drawing from his experiences as a trialist who worked with some of the most influential minds, he offers practical tips to young doctors. Finally, Ankur asks Chuck about the Impella device controversy and the recent decision of Abiomed to accelerate their clinical research. How should you start building a research programme? What are Chuck Simonton’s thoughts on the relationship between doctors and the industry? What is Chuck’s message to young cardiologists? Tune in to listen to this week’s episode of Parallax. Hosted by @AnkurKalraMD. Produced by @RadcliffeCARDIO. Submit your questions to Ankur via: podcast@radcliffe-group.com.
We discuss the various aspects of cardiogenic shock including definition, heterogeneity, classification and management with an internationally renowned expert in the field Dr Navin Kapur. Dr Kapur is the Director of the Acute Mechanical Circulatory Support Program at Tufts University School of Medicine, Boston, MA. Listen, like, subscribe, and give us a high rating.
Today we are reviewing the Top 10 performing Stocks over the last decade, in the S&P 500. Below are the best performing stocks of the last decade. 10.) Old Dominion Freight Line (ODFL) - Old Dominion Freight Line, Inc. operates as a less-than-truckload (LTL) motor carrier in the United States and North America. It provides regional, inter-regional, and national LTL services, including expedited transportation. The company also offers various value-added services, such as container drayage, truckload brokerage, and supply chain consulting. As of December 31, 2019, it owned 9,296 tractors, as well as operated 236 service and 42 maintenance centers. Old Dominion Freight Line, Inc. was founded in 1934 and is based in Thomasville, North Carolina. 9.) Ulta Beauty (ULTA) - Ulta Beauty, Inc. operates as a beauty retailer in the United States. The company's stores offer cosmetics, fragrances, skincare and haircare products, bath and body products, and salon styling tools; professional hair products; salon services, including hair, skin, makeup, and brow services; and others, including nail products and accessories. 8.) Align Techonologies (ALGN) - Align Technology, Inc., a medical device company, designs, manufactures, and markets Invisalign clear aligners and iTero intraoral scanners and services for orthodontists and general practitioner dentists, and restorative and aesthetic dentistry. 7.) Regeneron Pharmaceuticals (REGN) - Regeneron Pharmaceuticals, Inc., a biopharmaceutical company, discovers, invents, develops, manufactures, and commercializes medicines for treating various medical conditions worldwide. The company's products include EYLEA injection to treat wet age-related macular degeneration and diabetic macular edema (DME); myopic choroidal neovascularization; and diabetic retinopathy in patients with DME, as well as macular edema following retinal vein occlusion, including macular edema following central retinal vein occlusion and macular edema following branch retinal vein occlusion. 6.) United Rentals (URI) - United Rentals, Inc., through its subsidiaries, operates as an equipment rental company. It operates in two segments, General Rentals; and Trench, Power and Fluid Solutions. The General Rentals segment rents general construction and industrial equipment, including backhoes, skid-steer loaders, forklifts, earth moving equipment, and material handling equipment; aerial work platforms, such as boom lifts and scissor lifts; and general tools and light equipment comprising pressure washers, water pumps, and power tools. 5.) Abiomed (ABMD) -Abiomed, Inc. engages in the research, development, and sale of medical devices to assist or replace the pumping function of the failing heart. It also provides a continuum of care to heart failure patients. The company offers Impella 2.5 catheter, a percutaneous micro heart pump with integrated motor and sensors for use in interventional cardiology; and Impella CP, a device used by interventional cardiologists to support patients in the cath lab and cardiac surgeons in the heart surgery suite. 4.)Broadcom (AVGO) - Broadcom Inc. designs, develops, and supplies a range of semiconductor devices with a focus on complex digital and mixed signal complementary metal oxide semiconductor based devices and analog III-V based products worldwide. The company operates through three segments: Semiconductor Solutions, Infrastructure Software, and Intellectual Property licensing. It provides set-top box system-on-chips (SoCs); cable, digital subscriber line, and passive optical networking central office/consumer premise equipment SoCs; Wireless local area network access point SoCs; Ethernet switching and routing application specific standard products; embedded processors and controllers; serializer/deserializer application specific integrated circuits; optical and copper, and physical layers; and fiber optic laser and receiver components. 3.) Transdigm ( TDG) - TransDigm Group Incorporated designs, produces, and supplies aircraft components in the United States and internationally. The company operates through three segments: Power & Control, Airframe, and Non-aviation. 2.) MarketAxess Holdings Inc (MKTX) - MarketAxess Holdings Inc., together with its subsidiaries, operates an electronic trading platform that enables fixed-income market participants to trade corporate bonds and other types of fixed-income instruments worldwide. It offers institutional investor and broker-dealer firms the access to global liquidity in U.S. investment-grade corporate bonds, emerging markets and high-yield bonds, Eurobonds, U.S. agency bonds, municipal bonds, leveraged loans, and other fixed-income securities. 1.) Netflix (NLFX) - Netflix, Inc. provides subscription streaming entertainment service. It offers TV series, documentaries, and feature films across various genres and languages. The company provides members the ability to receive streaming content through a host of Internet-connected screens, including TVs, digital video players, television set-top boxes, and mobile devices. It also provides DVDs-by-mail membership services. The company has approximately 167 million paid members in 190 countries. Netflix, Inc. was founded in 1997 and is headquartered in Los Gatos, California. This show was originally recorded on Dec 21 2019
COVID, obesity, heart failure, Impella, and fitness are the topics John Mandrola, MD, discusses in this week’s podcast.
A case report of COVID myocarditis and cardiogenic shock is presented by Dr. Travis Howard with additional teaching by Dr. Zach Il'Giovine, cardiology fellows at the Cleveland Clinic. Dr. Nir Uriel, Professor of Medicine at Columbia University and Director of Advanced Heart Failure and Transplant at NewYork-Presbyterian Hospital Network in New York joins to discuss COVID-19 myocarditis and management of cardiogenic shock. The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. Check out the Cardionerds Cardiology Case Reports Topic Page Check out the Cardionerds Topics and Episode page for all podcast episodesSupport our educational mission by becoming a Patron! Case Summary Healthy and physically fit incarcerated 49M who presents with 2 weeks of fevers, myalgias, and SOB. His past medical history includes GSW to abdomen, psoriasis not currently on medications, prior tobacco and alcohol abuse. Transferred for undifferentiated shock on norepinephrine, and was found to be in sinus tachycardia to 110 bpm, hypotensive despite vasopressor infusions with labs showing a hyperinflammatory state, multi-organ failure, and eventually found to be COVID+. The patient quickly progressed into refractory cardiogenic shock requiring VA-EMCO, as well as Impella placement for LV unloading. The patient underwent endomyocardial biopsy with electron microscopy which was notable for COVID virions in the myocardium and was diagnosed with COVID myocarditis. Interestingly, his chest CT showed normal lung parenchyma and therefore presented as isolated cardiac involvement of COVID-19. The patient improved with tocilizumab, IVIG, and steroids. Episode Producer: Colin Blumenthal, MDMedical Education Mentor: Karan Desai, MD Episode graphic by Dr. Carine Hamo The CardioNerds 5! - 5 major takeaways from the #CNCR case Diagnose Cardiogenic Shock at the Bedside! Exam: Narrow Pulse Pressure, Labored Breathing, Cheyne-Stokes Respirations, Abdominal Bloating/Nausea, Cool Extremities, Oliguria, Altered Mental Status If PAC available, low central (PA) mixed venous saturation (
I hope all will listen to this important interview. Men's Health and how Jay Sanchez survived a major heart attack with the help of Dr. Mark Zolnick and Dr. Timothy Vellinga and the Impella pump. Lillian Cauldwell's Interview with Jay Sanchez on surviving a Heart Atack. “ Jay Sanchez, a military man with no history of heart trouble walks into the emergency room of a hospital and passe out with a massive heart attack in the emergency department at St. Vincent's Hospital in Santa Fe, New Mexico. As soon as Jay arrived, he suffered a massive heart attack presenting as cardiac arrest. Physicians quickly started CPR and shocked Jay four times. Jay was in cardiogenic shock. He was rushed to the catheterization lab where an intra-aortic balloon pump was placed along with multiple stents, but his heart was still failing as he was going into organ failure.”To contact Lillian Cauldwell: pwrnetworkllc@gmail.comI hope all is going well for you and your family. Jeanne White, Station Manager, Passionate World Talk Radio
Welcome! Craig discusses the danger of insider threats by those employees who are planning on leaving and behaviors that might indicate trouble. For more tech tips, news, and updates visit - CraigPeterson.com --- Read More: 60% of Insider Threats Involve Employees Planning to Leave --- Automated Machine Generated Transcript: Insider threats are real and it's not like what they're showing in the movies. Hey, not at all. And especially in this post-COVID-19 world, everything has changed. So let's talk about insiders, people in your business, and the types of threats they're presenting. [00:00:25] Hey, you're listening to Craig Peterson. You can find me online@craigpeterson.com and of course podcasts pretty much everywhere out there. Just search for my name, Craig Peterson. Well, we've been talking about some of the threats that are facing us right now. We talked about DNS already today. We've talked in the past about just dozens of different types of threats. [00:00:50]insiders are a big threat to businesses. So what does a threat look like? Well, Securonix just. Did a report, their researchers analyzed more than 300 confirmed incidents as part of their 20, 20 Securonix insider threat report. Now what they found was very disturbing, frankly. And the most disturbing part of it, at least to me was that 62% of the threats have to do with employees, exfiltrating data. [00:01:29] In other words, employees taking data. Out of the business. Think about where we have been with the whole Wu Han virus and the concerns about the COVID-19. We have taken our employees. Who've been coming into the office maybe since your business was founded? And said, Hey, stay home. But if you want to get paid, you still have to do some work for us. [00:01:56] And so we're allowing them to use their computers at home, maybe to bring a business, computer home, and then we hastily set up VPNs and other equipment in order to allow them access to the servers and the information they needed to use at home. How many of us put up. Monitors on those systems to make sure they weren't downloading stuff that they shouldn't have access to. [00:02:26] Do you have all of the permission set up properly on your file server? Do you have it set up so that if all of a sudden they're downloading all of the schematics for all of your systems, all of your designs, do you have it set up? So it's going to automatically shut them off and notify you. About what just happened? [00:02:47] Well, if you're like most businesses, the answer to that is no, because frankly, most businesses are not taking care of security. And that's what was pointed out here in this Securonix insider threat report because we've also allowed our employees to put documents on two thumb drives and take those thumb drives home, take them on the plane with them, maybe where they get lost. [00:03:15] But the number that is concerning about the data being at home is an 80% number. Now, this is where we get into something called a flight risk. These are employees that are within two months of leaving your organization because what they've found is that employees that are planning on leaving the business tend to start stealing data between two and eight weeks before they go. [00:03:47] And more than 80% of the employees that are planning to leave, bring. The business's data with them. That is very, very concerning. So think about that sales guy. How many times I mentioned this before, who's planning on walking out with all your customer lists that happened to me. I had a sales guy who was calling and trying to build a business and was keeping track. [00:04:16] Of course of everybody he had contacted. Right. Doesn't that make sense? So it's all in our database of all of the contacts that he had made and the discussions they had had, the types of needs that they had, and he downloaded all of them. And then he went to one of my competitors and he started calling all these people up again and continued on the sales process. [00:04:46] Just like he was still working for me. So here I was, I had paid for all of this Goodwill to be developed with these leads. I had paid for his training. He was going to training two to three days a week for a few hours back before we were doing it all live on a, on WebEx. Right. So he was going to all of these pieces of training. [00:05:10] He was taking people out to lunch. He was going to meet with them. And these prospects that were still in that sales funnel were called up by him. When he went to his new employer now, I kind of thought that I was the lone ranger here. Right. It really disappointed me. I thought I knew the guy. I thought everything would be fine. [00:05:35] And I eventually did talk to him cause I was. Too upset to talk to him initially. And I called him up and said, so how are things going? I said, Hey, I just heard from company X. And you know, they were working with us, we're moving along. And he said that you called him and suggested that they don't work with mainstream, that they work with your new employer. [00:06:01] And I stopped right there. Right? I didn't say another word. And he ended up responding. Yeah. Well, you know, they're my contact. I know them. I have a relationship with them. So I took them with me. Now we've seen similar things recently in the news when it comes to Tesla and Volkswagen, where Oh, they worked for me, and then he took all of this data with him. [00:06:28] Right. You've heard about that story. I'm sure. But apparently this happens all of the time, these flight risk employees and these individuals, according to this study were involved in about 60% of the insider threats. There were analyzed in this study and insider threats, makeup in case you didn't know the majority. [00:06:55] Of problems when it comes to data loss for the business. So what are you doing about it? Most people who are exfiltrating, the sensitive information are doing it over email. So are you monitoring their email? This was a pattern that they found in nearly 44% of the cases. Do you have special filters that are looking for this stuff? [00:07:18] You know, when we go into a business, we put filters in place on the email, looking for things like client numbers, looking for things like employer, identification, numbers, bank, account numbers. Driver's license numbers, everything for, you know, a GDPR standpoint, the Massachusetts standpoint, the California standpoint, the new federal guidelines that are in place, right. [00:07:42] We're looking for all of this data, but it also protects the company. Because they are trying to exfiltrate your data and take it with them to their next employer. So number one was they try and send it out by email and they'll often send it to a Gmail account or something else that they have the next most popular method is uploading it to cloud storage websites. [00:08:11] And that's why we put a limit. On where people can go, right? We oftentimes will have the Dropbox enterprise installed or the Microsoft three 65 enterprise versions installed where they can upload files, but it is tightly controlled and we know what they're uploading. We know what they're downloading. Do you have those controls Impella in place? [00:08:37] There are other ways that they're doing it, but we've got to pull up our socks. Now we have to, as businesses protect our investment, which for many of us is our retirement money. Right. And we have to watch our employees. I'm afraid to say. Particularly with the high rate of turnover in some industries and in the security industry, we're seeing the turnover rate that is in the sixth-month timeframe. [00:09:05] So think about that. All of the training you did for that new insecurity employee, all of the systems that were set up. What's going to happen when they leave and take that data with them, that salesperson, the accounting people and on and on. So keep that in mind. We're seeing insider threats, being a very, very big threat to all of us out there. [00:09:29] They'll all. When we come back, we're going to be talking about looters and the eye iPhones. We'll talk a little bit about how does Apple protects the devices that you have paid for? Because. Man, they do want a pretty penny. You're listening to Craig Peterson, stick around because we'll be right back after this and make sure you get my email. [00:09:54] Craig peterson.com/subscribe. --- More stories and tech updates at: www.craigpeterson.com Don't miss an episode from Craig. Subscribe and give us a rating: www.craigpeterson.com/itunes Follow me on Twitter for the latest in tech at: www.twitter.com/craigpeterson For questions, call or text: 855-385-5553
COVID19, protests, Impella, Excel, Bayesian statistics, and journal retractions are discussed by John Mandrola, MD, in this week’s podcast.
Cardiothoracic critical care PA Brendan Riordan (@concernecus) shows us his initial approach to the patient in cardiogenic shock, including initiating mechanical support, managing ECMO (plus Impella), and eventual weaning and discontinuation of support. Some pearls Anticoagulation on VA ECMO can be titrated to bleeding risk, with a balance between bleeding and circuit longevity—the latter being … Continue reading "Episode 5: Cardiogenic shock and ECMO with Brendan Riordan"
Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: I'm Dr Greg Hundley from the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr Carolyn Lam: Greg, this issue features a very important, but rather somber subject and it talks about suicide attempts among LVAD recipients and the real-life data from the Assist-ICD study. Now we have to get to that and it's a very interesting discussion, but first, let's discuss a couple of papers and I'll start. Now, we know that extracorporeal cardiopulmonary resuscitation using extracorporeal membrane oxygenation or ECMO, for hemodynamic support has been shown to enhance survival for patients with refractory VF or VT out of hospital cardiac arrest. However, what are the effects of prolonged CPR on development of metabolic derangements and neurologically favorable survival in these patients? Well, this was examined by Dr Bartos from University of Minnesota School of Medicine and colleagues who retrospectively evaluated survival in 160 consecutive adults with refractory VF/VT out of hospital cardiac arrest, treated with extracorporeal cardiopulmonary resuscitation, and compared these with 654 adults who had received standard CPR in the amiodarone arm of the ALPS trial. They found that extracorporeal CPR was associated with improved neurologically favorable survival compared to standard CPR at all CPR durations less than 60 minutes. However, CPR duration remained a critical determinant of survival with a 25% increase in mortality with every 10 minutes of CPR beyond 30 minutes. The progressive metabolic derangement which developed during prolonged CPR was associated with reduced neurologically favorable survival. Dr Greg Hundley: This mirrors an article that we had maybe about a month ago. What are the clinical implications of this particular study? Dr Carolyn Lam: Well, healthcare systems utilizing extracorporeal CPR for out of hospital cardiac arrest should optimize pre-hospital and in-hospital processes to minimize time to CPR. Further research is needed to identify strategies to increase CPR efficiency, improve profusion, and decrease the metabolic demands such that the progressive metabolic derangement associated with prolonged CPR can be delayed. This is discussed in an editorial by Dr Sonneville and Schmidt. Dr Greg Hundley: Very nice, Carolyn. Well, my next article is from Roxana Mehran from the Icahn School of Medicine at Mount Sinai. It's really getting at the issue of high-risk implantation of inter-coronary stents and balancing where is that risk. Is it from bleeding or a complication from the procedure? In this study, they had a total of 10,502 patients and they were included from four registries. 3,507 were identified as having high bleeding risk. The authors aimed to evaluate the long-term adverse events in the high bleeding risk patients undergoing PCI with cobalt chromium, everolimus-eluting stent implantation. Dr Carolyn Lam: Ah, Greg. Awesome. I'm a fan of Dr Mehran and looks like I'm going to be a fan of this study. What did they find? Dr Greg Hundley: Well, Carolyn, I love just thinking about coated stents. How about that? Interestingly, those at high bleeding risk had more comorbidities. They had higher lesion complexity and a higher risk of four-year mortality. In fact, four times that of those without those risk factors. The risk of mortality was increased after coronary thrombotic events and after major bleeding. Thus, rather than just being evaluated as a subset of patients in whom the risk of bleeding takes precedence, high bleeding risk patients must be considered a vulnerable population in whom both ischemic as well as bleeding events have a significant impact on their mortality. Dr Carolyn Lam: Nice, Greg, and you said all of that without repeating everolimus. Dr Greg Hundley: Coated, remember, coated stents. Dr Carolyn Lam: These tongue twisters, but hey, my next paper provides novel insights into mechanisms underlying diastolic stiffness in cardiomyocytes and the myocardium. This is from Dr Prosser from Perelman School of Medicine in Philadelphia and colleagues, who interrogated the role of the microtubule network in the diastolic mechanics of human cardiomyocytes and myocardium. They found that stable detyrosinated microtubules contributed viscous forces during diastolic stretch that increased cardiomyocyte stiffness, particularly in patients with heart failure. Depolymerizing microtubules reduced myocardial stiffness over the range of strains and strain rates associated with early rapid filling in tissue from patients with diastolic dysfunction. Dr Greg Hundley: Now, how are we going to take this to patients? Are there any translational insights? Dr Carolyn Lam: Microtubule deep polymerization using colchicine. Colchicine, the stuff we use for gout, this reduced myocardial viscoelasticity with an effect that decreased with increasing strain. Post-hoc subgroup analysis revealed that myocardium from patients with heart failure reduced ejection fraction were more fibrotic and elastic than myocardium from patients with heart failure preserved ejection fraction, which were relatively more viscous. Now, colchicine reduced viscoelasticity in both HFpEF and HFrEF myocardium, but may confer greater benefit in conditions with limited myocardial fibrosis including HFpEF. How's that for translational? Dr Greg Hundley: Oh, very nice, Carolyn. My next paper comes from Dr Lior Zangi from Mount Sinai School of Medicine. Carolyn, in this study, the authors performed transcriptomics sphingolipid and protein analyses to evaluate sphingolipid metabolism and signaling after myocardial infarction. They investigated the effect of altering sphingolipid metabolism through a loss of chemical inhibitors or gain modified MRNA and modified RNA of acid ceramidase function post hypoxia or MI. Dr Carolyn Lam: Whoa, so what did they find? Dr Greg Hundley: Well, Carolyn, translationally, the authors found that transiently altering sphingolipid metabolism through acid ceramidase over expression is sufficient and necessary to induce cardio-protection after myocardial infarction. Carolyn, these results highlight a new therapeutic potential of acid ceramidase modified messenger RNA in ischemic heart disease. The basic science is just phenomenal in our journal. Dr Carolyn Lam: It is, and I loved the way you explained that one, Greg, thanks. Now, there's lots of stuff also in the journal. There's an On My Mind by Dr Ray entitled "LDL Cholesterol Lowering Strategies and Population Health: Time to move to accumulative exposure model." We also have a research letter by Dr Chen describing a novel mouse knock-in strategy utilizing a biotin ligase-based system called biotin identification 2, to identify the cardiac diet proteome in vivo. Well, very interesting stuff, especially in terms of this particular novel strategy. Dr Greg Hundley: You know, Carolyn, this week the mailbox is just full, so I've got a research letter emphasizing trends in anti-arrhythmic drug use among US patients between 2004 and 2016 and it's from Dr David Frankel from the Hospital of the University of Pennsylvania. I've also got a letter to the editor regarding the association between the use of primary prevention implantable cardio defibrillators in mortality in patients with heart failure, a prospective propensity matched analysis from the Swedish Heart Failure Registry, and the corresponding author is Professor Laszlo Littman from atrium health at the Carolinas Medical Center in Charlotte, North Carolina. There is also a response to this letter from Dr Gianluigi Savarese from Karolinska Institute. Then finally I have a new another EKG challenge, Carolyn, from Dr Miguel Arias. It's a case of new onset, recurrent syncope triggered by fever. Can you get it right from just looking at the EKG? Well, Carolyn, should we head on to our feature discussion, which this week has a very somber tone? Dr Carolyn Lam: Let's go. Left ventricular assist devices or LVADs are really becoming established therapy for end stage heart failure. Now, we who manage such patients realize there are numerous complications and have seen patients who suffer things like anxiety and depression. Interestingly, until today, there was very little data regarding the suicide risk in this population. I am so pleased to welcome the authors of a very unique and important research letter and they are Vincent Galand as well as Erwan Flécher, both from Ren University Hospital in France, and of course Mark Drazner, our associate editor from UT Southwestern. Vincent, could you start us off by telling us what made you do this important study and what did you find? Dr Vincent Galand: As you know, in the entire population where a lot of tests have thromboses or infection or ventricular arrhythmias, but there is a lack of data about the clarity of life for the secret distress or suicide in this population. I think it's very important to have information about the population. At the beginning is the Assist-ICD study is a study focused on arrhythmias in this population, but we recorded data about suicide in this population. What the objective of this study was to analyze the incidents of suicide in this population and to see if there is some predictor of suicides in this population. Dr Carolyn Lam: What did you find? Dr Vincent Galand: We find that in centers without LVAD nurse coordinator, the incidents of suicide, was higher. It was not significant, but it was a very big trend. Additionally, we found that patient implanted in destination therapy was a bigger risk of suicide compared to patient granted bridge transportation or bridge to recovery. I think there is two factors of suicide. The first one is a lack of LVAD nurse coordinator and the second one is the implementation and destination therapy. Dr Carolyn Lam: Yeah, and the really cool thing is that that first factor is something that I suppose can be addressed in future efforts. Mark, could I just ask you to put these findings and this research that are into context for circulation to publish quite a specialty, if you may, topic, why is this so important? Dr Mark Drazner: DT vans are really a rapidly emerging therapy for patients with advanced heart failure, with almost exponential growth. As these profound technologies are emerging on the scene, it's important, first, to consider all the ramifications for our patients. I think anyone could imagine having an LVAD implant and how that might have profound influence on your life in totality and the impact on the psychological aspects. While there's been previous studies, there seems to be much avoidance in us really fully understanding the total impact. There have been previous case reports of suicide, but not anything to this magnitude where a systematic series with an estimate of the frequency of as high as 2%, which may not sound high, but, compared to the general population, is increased. We view this as an important look at a critical topic. It's the beginning, there needs to be, as you said, it's a research writer on a case series, but it's a cautionary tale and really is pointing the way for us to proceed with further investigation as potentially important complication related to that. That's essentially why the editorial board found this interesting. Dr Carolyn Lam: Indeed. Could you just remind us how big this study was? Because this is really big for an LVAD study. Dr Erwan Flécher: We collected data from 19 university centers in France over 10 years period and we collected a lot of that especially in the fields of arrhythmia. As Vincent said, we thought it was interesting to take the entire picture, so we collected data about quality of life and how do they live and if they had a lot of risk of suicide, if not, and that's how we succeeded to lead this study. In France, what is important also for you to know is that we do implant a different population of patients than in the US. We do implants in bad patients, in very, very sick patients. Most of them are currently in cardiogenic shock or already under temporary support, ECMO support, IMPELLA support, so it may impact also our results. That's an interesting point to say and the overall thing is that our paper demonstrated, I think, that we need to take care of these patients not only about the device, not only about the anticoagulation, but also, I mean again, the entire picture. The social part, the quality of life, the way they do live is very important. Probably they should be proposed for psychological follow-up also, or any kind of support for the family. This is important in order to decrease the risk of suicide, in my opinion. Dr Carolyn Lam: I liked those take-home messages that are very practical, and you kind of read my mind about that question of generalizability. Mark, did you have any reflection on that? The generalizability to the US population? Dr Mark Drazner: Yeah, that's an important point. I was struck in the paper that 80% of the patients who committed suicide were followed at centers without LVAD coordinators. That number seems high compared to what we're used to seeing. It would be intriguing how widespread that is, where patients who are getting implanted don't have access to a VAD coordinator in your country. Dr Erwan Flécher: Well, that's an important point also. It is different in France. I mean, we just created...That coordinator did not exist a few years ago in France and I know you are used to work with VAD coordinator in the US, in the UK, even in Netherlands and Germany, but in France it was not like that and all patients were only followed by cardiologist or cardiac surgeons and a few centers started few years ago, five, eight years ago to have a VAD coordinator nurse program. We do believe it is very, very important. That's also plea for a better organization of care in our country. Dr Mark Drazner: Yeah, that's a thinking point. I didn't realize that that was not widespread practice and relatively new implementation. It'll be interesting to see if the rates subsequently fall with that change in practice. Can I ask, let me follow up in terms of your previous comment. It sounds like a lot of these patients were acute presentations and I wonder also whether they may not have had the full time to grasp exactly what they were getting into, for example. I think we've all been there. Someone went into cardiogenic shock, ends up crashing and burning and has to go for a durable VAD. A very different complex in someone who has consolidation has been followed in the center for a while, has a chance to come to understand what all that really is. You think that is a major factor in this experience? Dr Vincent Galand: We think that patients who are granted in case of emergency; it's a bigger risk of surgical distress afterwards the implantation. In fact, that they cannot many information before the implantation, information about the worth life after the LVAD implantation. Of course if they don't the information, they can't be prepared for life after surgery. I think it's a bigger risk, yeah. Dr Erwan Flécher: That's why maybe in your country or maybe elsewhere, I don't know, maybe the findings would have been different. That's, that's an option we should consider, also. In France, as we told you, we do implants. Most of our patients are implanted in emergency. They're already in ICU. Most of them are already under mechanical ventilation, so they just wake up and they learned that they have been implanted. Not all of them, but most of them, the vast majority of them, so of course they are not so well prepared and that may have an impact on the follow-up. We try to talk to the family; we try to talk to the general practitioner. Dr Mark Drazner: Of the 10 patients, it's very interesting that patients are being implanted and not knowing they're being implanted in and say waking up with an LVAD. I don't know if you have the granular detail, but do you know, of these 10 patients, how many of them were in that situation? Dr Vincent Galand: The patients were implanted in cardiogenic shock, so I think it's four patients, but six patients were implanted without cardiogenic shock. They received this kind of information before the LVAD implantation, so it's not a big part of the population, but it's some patients. Dr Mark Drazner: Could you, just for our readers, it's a little goory, I will admit, but in terms of how these patients attempted or actually committed suicide, just to explain in terms of, it was oftentimes related to a mechanism through the LVAD. If you could just summarize that and how they tried to commit suicide or commit suicide. Dr Vincent Galand: That was the case. The suicide was with drive line disconnection or drive line section. In two patients, it was drug suicides, but in most of the patients the drive line is the main way for suicide. Dr Mark Drazner: It's interesting that the mechanism that these patients tried to commit suicide was directly through the LVAD. Dr Erwan Flécher: Of course it's the easiest way to terminate their life and they just cut off it. Just don't plug the battery and they are alone and that was the main way to practice their suicide. Dr Mark Drazner: I know we don't have the initial report, we probably don't have all those, but in terms of you postulating in the paper why patients might get to the state where they would try or commit suicide with the LVAD. If you just want to throw out some of your hypotheses so that our listeners can hear those as well. Dr Erwan Flécher: I've got in mind two or three points in order to improve our results. First of all, we should implant maybe earlier patients in France in order to have a better way to prepare and to invest the VAD implantation. The second point would be to have a better organization of care and I think we should develop that VAD nurse coordinators program like in many countries. We still have some but not in all the hospitals implanting that. The third point would be also to get the better LVADs. I mean, probably the drive line in sections, batteries, the controller, this of course it's much better than it was 10 years ago. There is no noise. It's less big than it was, but still, I think if we can improve the device itself, I think we may observe maybe the decrease in the risk of a system in society, especially the drive line, if there is no drive line, the quality of life should be better. We may suggest that the risk of suicide would decrease. Dr Carolyn Lam: A very somber topic, but those last take home messages, leaving hope for improvement, were really important. Thank you everyone for sharing with us today, and thank you, audience, for joining us today. Dr Greg Hundley: This program is copyright, the American Heart Association 2020.
In this edition of Device Week, Medtech Insight's managing editor Marion Webb talks with deputy editor Reed Miller about his recent story on Abiomed's plan to counter unfavorable study outcomes of its Impella heart pump. Medtech Insight articles addressing topics discussed in this episode: AbioMed Launches Plan To Counter Unfavorable Impella Data https://medtech.pharmaintelligence.informa.com/MT126227/Abiomed-Launches-$100M-Plan-To-Counter-Unfavorable-Impella-Data Start-Up Spotlight: BioIntelliSense Launches New FDA-Cleared BioSticker For Remote Monitoring Of Patients' Vital Signs https://medtech.pharmaintelligence.informa.com/MT126231/StartUp-Spotlight-BioIntelliSense-Launches-New-FDACleared-BioSticker-For-Remote-Monitoring-Of-Patien Knees Boost Zimmer Biomet; Turnaround Continues, But FDA Woes Linger https://medtech.pharmaintelligence.informa.com/MT126216/Knees-Boost-Zimmer-Biomet-Turnaround-Continues-But-FDA-Woes-Linger Boston Scientific Expects Up to $40M Impact In Q1 From Coronavirus Outbreak; 10%-12% Revenue Increase For 2020 https://medtech.pharmaintelligence.informa.com/MT126214/Boston-Scientific-Expects-Up-To-40M-Impact-In-Q1-From-Coronavirus-Outbreak-1012-Revenue-Increase-For For more information on Medtech Insight and to start a free trial, click here: http://bit.ly/2w7LnlR
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! […]
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! […]
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! Read More »
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! Here are some of my other posts to …
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! Read More »
Mechanical circulatory support (MCS) devices are becoming more prevalent and sophisticated with each passing year. In this episode, I’ll briefly cover some of the basics for intra-aortic balloon pumps (IABPs), Impella, CentriMag, ProtekDuo, TANDEMHEART, and ECMO. As always, drop me a comment with your questions and thoughts! Here are some of my other posts to …
Dr Carolyn Lam: Welcome to Circulation On the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: I'm Dr Greg Hundley, also Associate Editor, the Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr Carolyn Lam: Say, Greg, you know the feature paper this week talks about the perennially hot topic now and that is transcatheter aortic valve replacement or TAVR or TAVI. It's actually data from the France TAVI Registry comparing balloon expandable versus self-expanding transcatheter aortic valve replacement. I'm sure you want to hear more about it, but first I'm going to tell you about another paper in the same issue, this time also comparing a balloon expandable versus a self-expanding transcatheter aortic valve implantation, but data from a nationwide analysis and from corresponding author Dr Fauchier from Centre Hospitalier Universitaire Trousseau. He and his colleagues basically did a head to head comparison of the two competing transcatheter aortic valve replacement technologies that have been published but have not really been followed for long-term clinical outcomes. This was comparing balloon expandable versus self-expanding technology. They collected information from more than 31,000 consecutive patients treated with Tavern in France between 2014 and 2018 and based this on the French administrative hospital discharge database. They did propensity score matching, which was used for the analysis of outcomes according to the Sapien 3 balloon expandable versus the Evolut R self-expanding TAVR technology and studied this as nationwide level in France. Dr Greg Hundley: Wow. Carolyn, 31,000 patients. That's a really large study. What did they find? Dr Carolyn Lam: They basically found that balloon expandable TAVR was associated with lower mortality rehospitalization heart failure and pacemaker implantation compared with the self-expanding TAVR. Now, that's of course a pretty big finding and this is discussed along with the feature paper that we're going to hear about in an editorial by Drs. Abdel-Wahab and Thiele from Heart Center Leipzig. I want to tell you about another paper before I let you tell you about yours, okay? Dr Greg Hundley: Sounds great, Carolyn. Dr Carolyn Lam: Greg, what is your clinical impression of Impella use in the United States among patients undergoing PCI? Do you think it's increasing or decreasing over time? As a reminder, Impella was approved for mechanical circulatory support in 2008, so from then, what do you think? Dr Greg Hundley: You know, Carolyn, I really think it's increasing, especially used more frequently rather than an intra-aortic balloon pump. How about you? What's going on in your area of the world? Dr Carolyn Lam: My impression too, but you know, you're lucky because we now have data looking at the trends in Impella use, but in the United States, and this comes from the corresponding author, Dr Amit Amin from Washington University School of Medicine and colleagues who describe clinical outcomes and costs across U.S. hospitals in PCI patients treated with mechanical circulatory support, which is either the Impella or the intra-aortic balloon pump. They found that among more than 48,300 real world patients undergoing PCI with mechanical circulatory support at 432 hospitals between 2004 and 2016 in the Premier Healthcare Database, Impella use was indeed found to be rapidly increasing with marked variability across hospitals and not only its use, but also in its associated adverse outcomes. When analyzed by time periods or at the level of the hospitals or at the level of the patients, Impella use was associated with higher rates of adverse events and higher hospital costs. Dr Greg Hundley: You know, I wasn't thinking about the higher rate of adverse events. You wonder sometimes, are we using a technology in a sicker group of patients? Did this study shine any light on that? Dr Carolyn Lam: Those are great, great thoughts. The authors concluded that the variability in Impella use, the variability in its associated outcomes, and the association of Impella use with higher adverse events and costs really, really underscore the need for better defining of the appropriate use of mechanical circulatory devices and that was what you indicated as well, Greg, and what we need there is adequately powered randomized clinical trials and prospective real world evidence, which we don't quite have yet. Until then, perhaps a more measured approach is needed in clinical practice that balances risks versus benefits in complex patients undergoing PCI who require mechanical circulatory support. Dr Greg Hundley: That's going to be really needed, I think in this era, especially with the results from this study. Well, Carolyn, I'm going to switch over to the world of basic science and the first study I'm going to talk about is from Dr Richard Lee from Harvard University and it's a very interesting study. Just as some background, current differentiation protocols to produce cardiomyocytes from human induced pluripotent stem cells are capable of generating highly pure cardiomyocyte populations, but these cardiomyocytes remain immature and they really more closely resemble the fetal state. As a result, they have a lower maximum contractile force, slower upstroke velocity, and immature mitochondrial function compared to adult cardiomyocytes. Also, they're prone to ventricular arrhythmias. During development, cardiomyocytes undergo a shift from a proliferative state in the fetus to a more mature but quiescent state after birth. The mechanistic target of Rapamycin mTOR signaling pathway plays a key role in nutrient sensing and growth, and Dr Lee and colleagues hypothesized that transient inhibition of the mTOR signaling pathway could lead cardiomyocytes to a quiescent state and enhance cardiomyocyte maturation. Dr Carolyn Lam: Wow Greg, I really love the way you explained that. That's so interesting. What did they find? Dr Greg Hundley: Among human induced pluripotent stem cell lines, transient treatment with Torin 1, an inhibitor of the mTOR pathway, shifted cells to a quiescent state and enhanced their cardiomyocyte maturity. Also, the investigative team suggests that further testing will be necessary to evaluate whether delivery of Torin 1 treated cardiomyocytes could reduce the risk of ventricular arrhythmias in newly differentiated myocytes derived from pluripotent stem cells. Really an important advance in this whole area of developing mature cardiomyocytes from our own pluripotent stem cells. Well, Carolyn, my second basic science paper comes from Dr Calum MacRae from Brigham And Women's Hospital, also at the Harvard Medical School. Carolyn, this study used both highly purified human pluripotent stem cell derived cardiomyocytes displaying physiological and molecular characteristics of atrial cells with human MYL4 mutations in a zebrafish MYL4 knockout model, which exhibited molecular, cellular, and physiologic abnormalities that parallel those in humans bearing the cognate mutations associated with definitive genetic causes of atrial fibrillation. Dr Carolyn Lam: Oh, that's really interesting. Is this new genetic predispositions that they discovered? Dr Greg Hundley: I think the answer's yes. They found there was evidence of increased retinoic acid signaling in both human pluripotent stem cell derived cardiomyocytes and zebrafish mutant models, as well as abnormal expression and localization of cytoskeletal proteins and loss of intracellular NAD and NADH, and thereby established a mechanistic link between the transcriptional, metabolic, and electrical pathways previously implicated in the atrial fibrillation substrate of MYL4. In the future, these data could lead to novel therapies for some patients with atrial fibrillation. Dr Carolyn Lam: Wow. That really is fascinating, Greg. Well, let me round up by telling you about some of the other things in the issue. There is a research letter by Dr Parish on the effects of Omega-3 fatty acid supplements on arrhythmias and here, these authors reported more comprehensively on atrial fibrillation and other arrhythmias using additional data extracted from linked electronic health records in the ASCEND trial, remember, which was 1 gram of Omega-3 fatty acid supplementation daily in people with diabetes but without known atherosclerotic cardiovascular disease. Dr Greg Hundley: Oh wow. That's fantastic, Carolyn. I've got a couple other really interesting articles in the issue. First there's an In Depth review from Dr Yvan Devaux from Luxembourg Institute of Health, and he discusses regulatory RNAs in heart failure. In a perspective piece, Dr Alejandro Lucia from Universidad European de Madrid discusses the role of aerobic and resistance training as a therapy in addition to prescribed medications in patients with resistant hypertension. Really interesting. Then finally, Dr Ify Mordi from University of Dundee examines metformin use and clinical outcomes among patients with diabetes, with or without heart failure, kidney dysfunction observations from the SAVOR-TIMI 53 trial in which Dr Bergmark and colleagues found that metformin use was associated with a reduction in all-cause mortality and cardiovascular death, but not due to myocardial infarction or stroke, particularly in patients without a prior history of heart failure. What could the mechanism be, if not related to presumed atherosclerosis? Dr Mordi and colleagues proposed possibilities, and Dr Brian Bergmark from the TIMI study group and the cardiovascular division of Brigham and Women's hospital at Harvard Medical School and colleagues, they write a very nice response. It's really interesting listening to how could metformin reduce events but not related to atherosclerosis? How about onto our feature article? Dr Carolyn Lam: You bet. Dr Amit Khera: This is Amit Khera, digital strategies editor for Circulation from UT Southwestern Medical Center joined by my colleague, Dr Dharam Kumbhani who's also an associated editor at Circulation and we're pleased to have Dr Eric Van Belle, Professor Van Belle, from Lille University Hospital to discuss the featured article today, "Transcatheter Aortic Valve Replacement Propensity Match Comparison From the France TAVI Registry." Welcome to you both. Dr Van Belle, I'm going to start with you and we always like to hear a little bit. Perhaps you can tell us some of the background, what led up to this investigation, what led to your group pursuing this manuscript? Dr Eric Van Belle: Nowadays, the TAVI procedure, the TAVR procedure, is becoming very prominent kind of way of treating patients without stenosis, and basically we have two different type of devices that are available to treat the patients. Once series is based on the balloon expandable concept and the other one on the self-expandable concept. These two type of devices are considered to be used primarily in every kind of patient. Theoretically, we can use any of these two devices, any kind of patient, if we follow the recommendation of the manufacturer and I'll just say that that'd been done. These two devices are being validated against surgery, so basically, we could potentially use any kind of them. In today, there is no direct and there was no direct comparison between the two different kinds of concept, although they are very different. Again, the device is different. The way we implant the device is different. The major question that we had behind was to say, okay, what is the outcome? If it's a mean patient get one of the devices or can we expect or should we expect a different outcome? That was the main question behind it. Dr Amit Khera: Okay, so essentially there's two valves, they're both being used fairly regularly and without any kind of direct comparisons. Tell us a little bit about the study design and what you found in this project. Dr Eric Van Belle: For methodology, we used what is called a French study registry, basically nationwide registry with almost all patients treated in France included, and we used it as a database of patients between 2013 and 2015 with an overall group of 12,000 patients treated with either of these two kinds of devices. This is one of the aspect of this registry. The other very important aspect of this registry, and that's the mortality data survival that was obtained in all the patients in 2008 through 2016, so we have a set of 12,000 patients. It was a cool kind of device with complete mortality data by April 2016 so basically, this is the main methodological aspect. On top of this, we did the best to do some matching on the older clinical variables and all the matching valuables that we had to create pairs of patients that could be matched to one to one. We had, at the end, a group of almost 4,000 patients. Dr Amit Khera: Okay and tell us a little bit about some of your main findings of this study. Dr Eric Van Belle: The two main findings were those differences between the two groups of patients, that is a patient treated with self-expandable devices at a higher risk of valvular regurgitation. This was mainly a confirmation because this finding was already reported previously in previous studies trying to compare the two devices, but what was more striking was the difference in mortality. It was a difference mostly in hospital mortality but also in mortality after two years. That was significant with an absolute difference in mortality around 3% by two years. Dr Amit Khera: Well, obviously important, as you mentioned that paravalvular leak had been seen before and this now a long-term mortality difference. Certainly an important finding and one of the main findings of your study. One of the concerns about comparative effectiveness research, essentially you're using observational data such as this is that there still could be residual confounding. There still may be patient characteristics or decisions made by interventionalists that aren't fully accounted for. How did you all really try to account for some of these components, this residual confounding to try to get the best answer that you could? Dr Eric Van Belle: That's going to be a major comment, and everything you can do, every best way to try to control for this, there is no better answer than to do a randomized study, and probably we'll discuss on this. Let's see, indeed, we try to do our best to minimize as much as we could, all these potential confounders, so we did it in a different way, indeed. The first way to do it was to adjust all the potential differences among group but what was very also interesting to remind is that, when you look at the 25 clinical and imaging variables and creating the aortic annulus diameter that was incorporated in the matching, that actually 21 of the 25 variables were already there. We were balanced between the two groups, existing that indeed most of the case, the operators, we are not so much directing or at least if there was selecting it was not captured but all of these valuables because again, out of 25, the correction needed to do the matching was only affecting 4 variables, mainly. Those variables were already pretty well-matched between the two populations. The other way we did it was to look at what is called falsification endpoint, that it is endpoints that are supposed to be unrelated to the devices to verify that indeed, we have not selected a population that will have issues that are not related to the device itself. We look at, let's say, mortality by infection, mortality by cancer, to verify that, indeed, this kind of event where it did well balanced between the two groups suggesting that the mortality effects that we observed was not related to this kind of unbalance related to something else that was not captured by analysis. Dr Amit Khera: Yeah, I think that was quite an important observation you mentioned. The first that these two groups are generally well-balanced to begin with, even before with all the matching parameters and then certainly the falsification endpoint helped to add validity to the findings. Dharam, I'm going to turn it over to you. Maybe you can show this from an associate editor's perspective. What are some of the observations you found interesting about this study and what are some of the considerations we had in some of the discussions about it? Dr Dharam Kumbhani: I'll just remind our listeners that this was also a late breaker at AHA last year in 2019, so this is really a very important finding. As Eric briefly pointed out, there haven't really been head to head comparisons between, the two dominant valves in the market even though TAVR has pretty much become the dominant strategy for treatment of aortic stenosis. At the end of the day, it's an observational analysis. We have to take the findings with that in mind. At a minimum, it's first a lot of debate and discussion about the need to have randomized trials and our belief that, perhaps, TAVR is a class effect may not always be true. I think that hypothesis would certainly need to be tested and that's what this paper really sparks as far as discussion going forward. Dr Amit Khera: Maybe I'll ask both of you. One of the challenges of any type of observational research is time period. First there was a hint towards even maybe a greater effect in the more recent time period than the distant time period. Also, there's always commonly changes in technology, especially interventional field where a study comes out and it's already obsolete because there's some new technology. There are some newer generations of valves that have come out. Do you think that it would affect these findings in any way? Maybe we'll start with you, Eric. Dr Eric Van Belle: That's always an issue. Again, because it's a very rapidly evolving field and if you want to have strong data, you need to have really long-term follow-up. You need to have mortality data. There is some kind of contradiction between both that the field is evolving very quickly but then to have solid data, you need to have some time. What we could say, indeed, as a study period was 2013 and 2015, but the device that we are using at that time were already really well matured and also the devices that were used at that time was usually the ones that were used for the comparison with the surgical techniques. Again, these devices are not so much obsolete since they were accepted and used again, when you need this one device study to compare with surgery. Of course these devices have still had some evolution and change, and it is for the good of the patient, but again, as mentioned there, I'm seeing what is very, very important is that this finding is, in my view, intriguing enough to say, okay, even if it's difficult to conduct this kind of randomized study, it has to be done now because we need to really know. Let's say 80% of the patients could indeed be treated with any of the two device in this large margin of patients. Do we have to choose one or the other one to start with? This has already been well answered in a larger randomized trial. Dr Amit Khera: Dharam, maybe I'll ask you, do you think this large randomized trial, are you optimistic that that would happen? Certainly it sounds like it's something that would be very helpful for the field. What are your thoughts on whether that's actually going to occur? Dr Dharam Kumbhani: I know that there are some head to head trials ongoing. I don't know if they will have the sample size to really drill down, as far as hard endpoints, mortality, for example. I think the field clearly needs it. The question is, who's going to sponsor a trial like that? There's probably not much incentive for industry to sponsor something like that. Really it would fall down to whether there's a way for government agencies to partner with industry or other ways to run this. I do agree with Eric that that's really very important and hopefully we'll see that in the field going forward. I did want to comment on the next iteration of devices as far as what we may see now. The mortality signal, I know we've talked about it. It's an observation study. It's hard to know if there's confounding, and even with all the sophisticated statistical analyses that the team did, there's always a possibility that somehow there was sicker patients that received self-expanding valves. The signal for paravalvular regurgitation is not just in this study. We've observed it in many other studies and for other self-expanding platforms as well. Both the SCOPE trial and the St. Jude trial last year, both came around the same time. They were self-expanding platforms and both of them showed a higher paravalvular regurgitation rate compared to the balloon expandable rate. That may be a real thing, and I don't know if that is an inherent design flaw in the self-expanding platform or if there are ways that that could be mitigated going forward. Again, I think the trials, for it to be meaningful, it would be obviously important to collect and have short term and imaging markers. Really, what the field needs is long-term evaluation of these two strategies. Dr Amit Khera: I want to take both Dharam Kumbhani and Dr Eric Van Belle l from Lille University Hospital. Thank you both for joining today. Dr Greg Hundley: This program is copyright, the American Heart Association 2020.
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode465. In this episode, I ll discuss the use of alteplase for suspected Impella device thrombosis The post 465: Use of Alteplase for Suspected Impella Device Thrombosis appeared first on Pharmacy Joe.
#82 - impella aumenta mortalidade?
Audio Summary by Dr. Julia Grapsa and Dr. Marat Fudim
In this special episode of the View, Dr. Peter Block, Dr. Kim Eagle, and Dr. Deepak Bhatt discuss highlights from Day 3 of AHA.19, including Evaporate: Icosapent Ethyl on Progression of Coronary Atherosclerosis in Patients With Elevated Triglycerides on Statin, the Treat Stroke To Target trial results, and Impella versus intra-aortic balloon pump in the United States.
Aspirin and ICH, late tPA for stroke, public reporting of outcomes, Impella, grapefruit juice and QT interval, and ICDs for primary prevention are discussed in this week’s podcast.
Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm doctor Carolyn Lam, associate editor from the National Heart Center, and Duke National University of Singapore. Dr Greg Hundley: And I'm Greg Hundley, associate editor from the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr Carolyn Lam: Have you heard of long non-coding RNAs? Well, they are definitely the hot topic and our feature paper today discusses the first demonstration of the importance of a linked RNA in atherosclerotic lesions not just in mice but also in humans. You have to listen on, it's coming up right after our copy chat. Greg, what are your picks upon the journal this week? Dr Greg Hundley: The first paper I wanted to discuss comes from France, and it's basically looking at ambulance density and outcomes after out of hospital cardiac arrest from Florence Dumas from Hôpital Cochin in Paris, France. This manuscript addresses the geographic disparities and survivorship of out of hospital cardiac arrest and the relevance of the patients characteristics versus whether ambulances are equipped with those trained in basic or advanced cardiac life support. So, what they did they had nineteen neighborhoods in Paris, and the number of BLS trained versus ALS ambulances was collected, and the authors assessed that respective associations of socio-economic characteristics of the patient population and the ambulance resources of these neighborhoods and compared those with successful return of spontaneous circulation or risk as the primary end point and then survival of out of hospital discharge as the second end-point. So, they had 80754 non-traumatic out of hospital cardiac arrests across the Paris area. 42% at ROSK 9% head survival at discharge, and after accounting for the patient's socio-economic status, greater than one and a half advanced cardiac life support ambulances per neighborhood and greater than 4 basic cardiac support basic life support units per neighborhood were associated with ROSK, but only the 1.5 ALS units per neighborhood were associated with survival. Dr Carolyn Lam: Oh, interesting Greg. So does this we need more advanced life support units? Dr Greg Hundley: So, Paul Dorian from St. Micheal's Hospital in Toronto, Canada wrote an excellent editorial, and one point he made related to these ALS units is that it was really a very small 1.3 adjusted odd ratio for survival to hospital discharge, and it's important to note that although the increase in survival was associated with more ALS units, there were many other variables that were likely important and not recorded in this study. For example, including the time to collapse, to calling for EMS, the time from the call to the deployment of that ALS unit to the scene, the time from collapse to the defibrillation, the total "no flow time" sort of in quotation, which is the total duration of collapse until CPR is started and so I think one of the points in this observational study is there could've been many differences that would've associated with the findings, interesting findings how about one of the papers that you liked? Dr Carolyn Lam: So, the paper that I selected here is a first time that a targeted anti-inflammatory therapy has been shown to reduce hospitalization for heart failure and at-risk patients. So, you know that some clinical inflammation associates with an increased risk of heart failure and associates with the worst prognosis in patients with heart failure, and yet, so far, treatments specifically directed at reducing inflammation in patients with heart failure have not been shown to improve clinical outcomes. That's why today's paper is so special and it's from Dr Everett and colleagues from Brigham and Women's Hospital Harvard Medical School in Boston, and basically, the authors looked at CANTOS and tested the hypothesis that the interleukin -1β inhibitor can canakinumab would prevent heart failure hospitalizations and the composite of heart failure hospitalizations on heart failure related mortality in the CANTOS trial. Now, remember the CANTOS trial randomized more than 10 000 patients with a prior myocardial infarction and with high sensitivity C-reactive proteins at least two or greater, and they were randomized to canakinumab 50, 150, and 300 mg or placebos. Now, before randomization, these participated were asked if they had a history of heart failure and 22% said yes so the current paper actually looks at this stratification of patients who said they had heart failure, and during a meeting follow-up of 3.7 years, 385 patients had a new heart failure hospitalization event. Now, here's the key: the authors found a dose dependent reduction in the risk of hospitalization for heart failure as well as the composite of hospitalization for heart failure or heart failure related mortality among those allocated to Canakinumab. Dr Greg Hundley: So, how does this differ from prior attempts targeting inflammation and heart failure? I mean is this ready for prime time thing? Dr Carolyn Lam: So, we have to bear a few things in mind here you know. CANTOS was different from a previously published randomized controlled trials, which were basically neutral and that was like of infliximab and etanercept so the drug in CANTOS targets interleukin-1 beta whereas the prior ones targeted the TNF-alpha, and also very importantly, CANTOS did not specifically enroll patients with an established heart failure only. CANTOS patients had to have a history of myocardial infarction and there was no data on their ejection fraction or natriuretic peptides at the time of randomization nor at the time of heart failure hospitalization. So, by the way, we don't know whether there's a differentially effect on hep pef versus hep-ref. So, again difference from the heart failure focused trial previously that used an anti-inflammatory agents. The other thing: although there was a dose dependent reduction in the risk of hospitalization for heart failure no single dose of Canakinumab compared to the placebo had a statistically significant reduction in the risk of heart failure hospitalization. Only the trend was statistically significant so all in all, this was a pre-specified aim of CANTOS to look at heart failure, the data presented here should really be considered hypothesis generally, but really quite promising. And what about you Greg? What's your other paper? Dr Greg Hundley: We're going to switch gears a little bit and shift over to the Jackson heart study. The large longitudinal cohort from Jackson, Mississippi that's recruited to follow for cardiovascular events, and it's an area of the United States where we have some of the highest cardiovascular disease event rates really across the nation so this study focuses on sleep apnea and is the Jackson's heart sleep study. It's a sub-study of this larger Jackson's heart study that involves 913 patients, and the investigators were looking at the association between sleep apnea and blood pressure control among those of a Black race. So, Dayna Johnson of Emerald University is the first author on the paper. What's nice about this sub-study, this sleep sub-study is that there are objective measures using an in-home type III sleep apnea study. They had clinical blood pressure measurements and then anthropometry as opposed to questionnaire derived data that may have been performed in the larger cohort. And the study determined these associations between moderate or severe obstructed sleep apnea with controlled, uncontrolled and resistant hypertension. So the analytic sample of the individuals with hypertension was 664, and they had an average age of about 64 years. They were predominately women 69%, obese 58%, College-educated at 51%. Among the sample, about a quarter had obstructive sleep apnea, which was untreated and unrecognized in 94% of the participants. That's an interesting point, just right there. Overall, 48% of the participants had uncontrolled hypertension and 14% had resistant hypertension. So, multiple medications, often four and still unable to control the blood pressure. So the findings participants with moderate or severe obstructive sleep apnea had 2 times higher odds' ratio of resistant hypertension. Dr Carolyn Lam: Whoa Greg, that's a huge risk and very important finding. I mean if sleep apnea could be modifiable risk factor perhaps for very important issue among African Americans resistant hypertension. What do you think about clinical implication? Dr Greg Hundley: One of the things to be considering now is what are we going to do about that cause as you know CPAP is really the preferred treatment for resistant hypertension, but it's efficacy hasn't been really that well studied in African Americans and CPAP tolerance is low so this study highlights for us potentially new mechanisms for resistant hypertension, but we still got to be thinking about what would be our next therapeutic intervention for this particular patient population. And what about your next study? Dr Carolyn Lam: The next study is about Impella support for acute myocardial infarction complicated by cardiogenic shock. Now, we use it all the time, but did you know that to date, there is no large randomized study actually comparing the use of Impella to other contemporary cardiac support devices and medical treatment in stem related cardiogenic shock. So, Dirk Westermann and colleagues from University Heart Center in Hamburg tried to address this knowledge gap by using a multi-national database of patients with acute myocardial infarction complicated by cardiogenic shock and treated with the Impella device and compared in a matched fashion their outcomes to patients from the IABP Shock II trial, which you would recall is a randomized trial which demonstrated similar outcomes between IABP and medical treatment in myocardial infarction in cardiogenic shock. So, they looked at 237 matched-pairs so remember this was pairs from this registry of acute myocardial infarction with shock and using an Impella matched with IABP shock patients and what they found was that there was no significant difference in 30-day all-cause mortality. Instead, severe or life-threatening bleeding and peripheral vascular complications occurred significantly more often in the Impella group when they limited the analysis to the IABP treated group as controlled versus Impella that was still the same results. Dr Greg Hundley: So, Carolyn, there are trying to match patient population from two different studies and they may have confounders in there that we can't account for so why we not able to produce large randomized trials of Impella devices in studies of patients with acute myocardial infarction? Dr Carolyn Lam: The rate of acute myocardial infarction complicated by cardiogenic shock has really declined in the past decade. Furthermore, clinical signs of shock really appear in half to three quarter of cases several hours after hospital admission so making randomization before primary PCI of the AMI really very difficult. And finally, many interventional cardiologists believe that there's equipoise that has already been reached on the use of these cardiac assistive devices in patients with cardiogenic shock and this was from registry data, and so if interventionists believe this then they also believe its unethical to randomize these patients in trials. Still, I think that current study to date really causes us to pause and to acknowledge that we really need to evaluate this better and prospective randomize trials of Impella treatment are warranted. Let's now go to our featured discussion, shall we? For our featured paper discussion today, we are talking about a basic science paper, and we have none other than the best of the best Dr Charles Lowenstein, our associate editor from University of Rochester Medical Center joining us as well as the first author of a really fantastic paper on long non-coding RNA in a specific type involved in arthrosclerosis and plaque formation. This first author is Sebastian Creamer from Goethe University in Frankfurt. Charlie, could you start us off by telling us what is a long non-coding RNA? We've heard a lot about this in recent times. What's the big deal about them? Dr Charlie Lowenstein: So in the last decade, scientists have learned that your genome, your DNA inside you, every cell codes about 20,000 genes and those 20000 genes encode proteins, but there are another 20000 genes that encode RNA only, RNA that never turns into protein that leaves RNA are an amazing diversity of different kinds of RNA really short micro RNA, longer RNA that defends the host from viruses and long non-coding RNA that have a huge variety of effects regulating genes, turning genes on and off in proliferation and cell growth and inflammation so long non-coding RNAs are increasingly appreciated as an important part of the genome. Dr Carolyn Lam: What a perfect set up with that. Sebastian, could you tell us about your study please? Dr Sebastian Creamer: Our laboratory was interested in non-coding RNAs for some time and previously, we've found that this specific non-coding RNA MALAT1 regulates endothelial cell functions and because we were interested in analyzing this particular RNA in the disease setting it shows at a risk growth so it's because also we saw that when it's regulated by flow and end of previous cells and so we cross MALAT1 deficient mice to Apoe mice and set them on a high fat diet and analyzed and subtracted in both groups. And while we only saw a modest increase in plaque size in MALAT1 deficient mice, we could appreciate a higher amount of inflammatory cells in plaque of aortic roots in those mice, which let us hypothesize that inflammatory responses was appreciated and is a very important contributor to arthrosclerosis in MALAT1 deficient mice. And to test this, we decided to transplant MALAT1 deficient bone marrow in Apoe knockout mice with MALAT1 and interestingly, we saw that now plaques were significantly larger than compared to mice who received controlled MALAT1 white cell bone marrow, and also inflammatory cells were more prominent in those mice. Dr Greg Hundley: Sebastian, this is Greg Hundley. You also did some experiments in human subjects. Could you tell us a little bit about those too? Dr Sebastian Creamer: So, because we saw this interesting phenotype, we were very much interested if this also translates into the human setting. Luckily, we got a really nice collaboration receding in Stockholm access to high impact material from patients with arthrosclerosis and what we could see here that MALAT1 expression was down regulated in patients with arthrosclerosis and it also correlated with disease progression. Moreover, in another collaboration, we consolidated those findings with experiments, which showed that human cells have less MALAT1 compared to normal vasculature. Dr Carolyn Lam: It all sounds so sensible and logical and so on but let me just frame this for our audience. This is actually the first time that it's been demonstrated. The importance of long non-coding RNA in arthrosclerosis. Charlie, could you tell us a little bit about how significant these findings are? Dr Charlie Lowenstein: Sure. So, I'm really interested in the final figure in this paper because there are lots of interesting human data, showing that MALAT1 expressed more in normal than atherosclerotic arteries and also that MALAT1 expression is correlated with fewer major adverse cardiac events so the whole story is a very nice story saying that the expression of this anti-inflammatory link RNA not only has an effect in mice but it can be extended into the human field of arthrosclerosis and inflammation. It's particularly important because there's a lot of attention in the last decade that inflammation drives atherosclerosis, and in light of CANTO trial showing that anti-inflammatory therapy can actually decrease atherosclerosis and decrease cardiovascular events in humans. This is important cause it shows another pathway, which regulates inflammation. Not only in mice, but also in humans, and in the human atherosclerotic setting. Dr Carolyn Lam: Amazing. Sebastian, what are the next steps? How far are we away from clinical applications here? What are the next steps to get it in the clinic? Dr Sebastian Creamer: So, the very difficult thing is that MALAT1 is down-regulated in atherosclerosis and also therapeutic approaches is very difficult in such a complicated disease like atherosclerosis to actually increase the expression of such a long non-coding RNA. What we are currently working on is to decipher more than the clinical malade-1 is actually influencing atherosclerosis so we have lots of hints or some evidence that adhesion of inflammatory substances altered and the bone marrow activity, which is very important in atherosclerosis and also in other cardiovascular diseases like myocardial infarction is altered so we think that malade-1 might actually influence the resolution of inflammation and when it's lacking, inflammation can be resolved. So, we are now putting somewhat mechanistic studies and finally, we hope that we can find another downstream target like micron AB, we talked about in our paper, which we can directly target in the future. Dr Charlie Lowenstein: So, I agree with Sebastian. I think MALAT1 is going to turn out as one of those major link RNAs that controls inflammation possibly controlling the way in which the bone marrow reacts to systemic inflammation and produces cells and then have those cells home in on various inflammatory targets so I think this is an important observation that's going to have not only implications for atherosclerosis but also for other inflammatory diseases. Dr Carolyn Lam: Excellent. If you don't mind, I would love to switch tracks a little bit. We find it that very special and we can discuss basic papers with people who can explain it so well because we understand that there's so much work that goes in to these papers and so on. Charlie, could you take behind the scenes a little bit with the editors and tell us what is it that circulation looks for in basic science papers that makes us published? Dr Charlie Lowenstein: We get a lot of really good basic science papers, and it's a challenge for the associate editors, and the editors to figure out what's right for circulation and let me use this manuscript as a great example because this is a terrific paper. So, this paper is divided into four sections, and these sections are what we look for in any basic science paper that's going to reach an audience of clinicians who are interested in pathways and therapeutics so this paper has a section on mice. There's a gene in mice that's important then the paper delves into cells what's happening with cells and then a little bit of mechanisms and genes and proteins and then this paper takes the observation back into humans and shows that there's some human and clinical relevance so this is not only a great paper, but it is a classic example of what the associate editors are looking for in a basic science paper that's targeted towards clinicians. Dr Charlie Lowenstein: There's some in vivo work with mice, there's some mechanistic work then they take it back to the humans. Plus, of course like anything that comes into circulation, it's going to be novel, interesting and has some important relevance to human cardiovascular disease. This paper that we're discussing is a great example of a paper that we love to publish in a circulation and it's a real tribute to Dr Dimmeler and her team and to Sebastian that they put this paper together and submitted it to us. Dr Carolyn Lam: Thank you audience for joining Greg and I today. You've been listening to circulation on the run. Don't forget to tune in again next week.
Statins in the elderly, donor hearts and the opioid crisis, Impella, coronary calcium in exercisers, and the plateau in heart disease deaths are discussed in this week’s podcast.
Dr Carolyn Lam: Hello. We're here at the American Heart Association meeting in Chicago where circulation has 19 simultaneous publications this year. And that is a huge increase from six in the past to 19, all thanks to the man next to me. But first, let me introduce myself. I'm Dr Carolyn Lam. I'm associate editor from the National Heart Center and Duke National University of Singapore. I'm the voice you hear on 'Circulation On the Run'. I'm so pleased to be here in person today with Dr Dharam Kumbhani. He's associate editor from UT Southwestern and he also leads the simultaneous publications for this journal. So big applause for this amazing bonanza this year. Dr Dharam Kumbhani: Thank you. Dr Carolyn Lam: Next to him, we have Dr Sana Al-Khatib and she's from the Duke University. And finally, Dr Gabriel Steg from University of Paris. Wow! Okay, we've got 19 papers to chat about. No, I'm just kidding. We're going to talk and focus on the seven simultaneous publications that were late-breaking science. Why don't you start us off, Dharam. We will first start with the interventional trials, and there were three of them. I'd love you to chat about the first of them, but even before that, maybe, tell us what it's like to get a simultaneous publication. Because I think people underestimate the amount of work it takes to do that. Dr Dharam Kumbhani: Thanks a lot, Carolyn. I think under Joe's leadership the whole space of simultaneous publications in late paying clinical science has really been a big endeavor for him and for the journal. We just have an amazing team that's able to work on this in very quick order. So, for the viewers, I think it's a very involved process, but it's a very gratifying process. We work very closely among the associate editors, the senior editors, and then the circ staff, and we have very rapid turnaround time. So we owe a lot of gratitude to our reviewers who frequently will turn these reviews in within 48 hours. Our goal has been that we respond back with a decision usually within five to seven days. So it's been very gratifying. Then it moves onto the next set of revisions, et cetera. But even among the papers that we are unable to accept for circulation, it's just a quick turnaround time for the authors so they haven't lost as much time and can potentially look elsewhere. It's been a really gratifying process. It's been a great, great team effort. I appreciate everything you said, but really I don't deserve all that credit. It's been a great team effort. Dr Carolyn Lam: No, it's been rumored there's a lot of lost sleep on your end, so thank you, thank you Dharam for this. And maybe you could open with the ISAR-TEST 4, that's been [crosstalk 00:02:47]. Dr Dharam Kumbhani: Yeah, well thank you. I think we had some really interesting interventional trials and Dr Steg will discuss a couple of them as well. ISAR-TEST 4 was a very interesting trial. It is one of the first 10 trials that gets to the 10-year mark, so this is just the 10-year follow-up results of that. It was about a 2500 patient trial. It was done in Germany, multiple centers. Really they were trying to assess the space that they were trying to ... Or the knowledge gap that they were trying to fill was the durability of the bioabsorbable polymer stents. Specifically, they were looking at a bioabsorbable polymer sirolimus-eluting stent, the Yukon stent, and then they compared that with durable polymer stents including Xience or the everolimus-eluting stent and then Cypher, which is no longer available in the U.S., but that's a permanent polymer sirolimus-eluting stent. The primary results were published and presented a long time ago. There was really MACE events at one year and it showed non-inferiority for this bioabsorbable polymer stent back then. So, then they had, incredibly, 83% of the cohort that they were able to follow-up out of 10 years. And what they showed is that ... I don't want to necessarily get into the numbers and the details as much, but what they showed is that this bioabsorbable polymer sirolimus-eluting stent tended to have similar outcomes to Xience, which we accept as state of the art current generation stent, permanent polymer. And it did better than the Cypher stent, both in terms of MACE events and stent thrombosis. So suggesting that, the big advance in the field for this is ... This is a long-term follow-up of the stent. It suggests that outcomes may be similar in this patient population. Although only 12% were really enrolled with an MI in this patient population. Most of them were stable or less sick ACS patients. And they show fairly good outcomes out of 10 years, comparable to Xience and better than Cypher. I think it was interesting. Gabriel, what is your take [crosstalk 00:04:57]. Dr Gabriel Steg: I think it's important. There's been a tremendous interest in international community on trying to tease out which are the best types of stents and beyond brands, try to understand the type of stent, the coating, the drug that you put on it, whether the polymer is durable or not durable. I think these types of fairly well done, large randomized trials with long term flow are critical. A lot of the focus in the interventional community originally was on lumen size, late loss, angiographic parameters short term. And now the field has matured, and we've moved to clinical outcomes, patient-oriented outcomes, long term follow-up. And it's important because we've learned from long term trials such as PROTECT that the result at one year may not predict what happens at five years, and sometimes you have surprises. So, it's really important. We owe it to our patients because these are irretrievable devices. Once you've implanted them, they are there. We talked about Cypher being out of the market, but there are more than a million patients who walk every day on this plant with a Cypher in their coronary artery, so we better know what the long-term follow-up is. Dr Dharam Kumbhani: Yeah, that's a great point. Dr Carolyn Lam: Wow. And then thanks also for the discussion that allows me, as a noninterventionist, to realize ... It's hard to keep track of what's happening with all the different types of stents and polymers and so on. But could you then summarize for the field, does that mean that these biodegradable ones are now ... Do I sound ignorant when I say that? That they are now really in the game. Is that what it does? Dr Dharam Kumbhani: This whole bioabsorbable field, there are nuances. So this really is testing a bioabsorbable polymer where - Dr Carolyn Lam: Oh! Dr Dharam Kumbhani: So, with every stent you have a stent, you have the polymer, and then you have the drug. Dr Carolyn Lam: Thank you. Dr Dharam Kumbhani: And so, the polymer and the drug go away, and then you're left behind with a bare metal stent. And that's this Yukon stent. Dr Carolyn Lam: Got it. Dr Dharam Kumbhani: The one that has been in the press a lot more is the bioabsorbable scaffold where the stent and the polymer and the drug, everything in theory should be gone at a certain period of time. So this is ... It's an important distinction though. Because I know that it's very confusion when you just say bioabsorbable and it's unclear if you're talking about the polymer or you're talking about the stent, itself. But this really was a bioabsorbable polymer issue, so you're left behind with a bare metal stent at the end of it. Dr Carolyn Lam: Got it, crystal clear, and thank you. That's cool. That's super. Dr Sana Al-Khatib: I agree, for an electrophysiologist too. Dr Carolyn Lam: But now, let's go into the AMI field. There were two trials that really spoke to acute management patients coming in with an AMI and with cardiogenic shock, for example. Gabriel, could you tell us a little bit about the IABP-SHOCK II trial, as well as the really talked about a door-to-unload IMPELLA Trial. Dr Gabriel Steg: The IABP II trial is a randomized trial looking at the benefit, or lack thereof, of intraaortic balloon pump in patients with cardiogenic shock and acute MI. It's been standard practice since the '60s to offer IABP pumping to patients with cardiogenic shocks and AMI. So, literally more than a million patients have been implanted with IABP, but the reality is when we look at the randomized trial evidence of benefit there was none. They were very small trials, inconclusive, underpowered. Professor Thiele from Germany and his colleagues deserve enormous credit for having had the courage to really do what needed to be done. A proper randomized controlled trial, of course open label. And what they found in IABP II, which they already reported a few years ago, was that there was no acute benefit of IABP on survival short term, or for that matter on many of the secondary clinical outcomes looked at in this trial. They subsequently reported one year mortality. What they did here is they gathered follow-up on almost all of the cohort at more than six years. And they found that the long term survival is identical for patients who received an IABP and those who did not. So I think this nails the issue. But there's another thing we learn. The mortality at six years is staggering, it's close to 60%. And although a large fraction of the patients die in the first 30 days, you still have an additional 10% of patients who die between the first year and six years. So there still remains a very sick patient population for whom we need to investigate new strategies. I don't think it's going to be necessarily mechanical. We have to think of all of the strategies we do to prevent and mitigate cardiogenic shock to build up. And that's gets us to the second trial that I'll talk to you about in a minute. Dr Sana Al-Khatib: I have a quick question about this. Did they provide any information about modes of death in these patients? Dr Gabriel Steg: Yes. They did capture information about that. Off the top of my head, I'm unable to provide information, but yes they did capture that. The German system allowed them to retrieve information about causes of death and it's a closed system. It's a national trial, so they were able to get enormous follow-up. Dr Sana Al-Khatib: Because this information can help us inform what interventions are needed next. Dr Gabriel Steg: Yes. That's really important. Dr Dharam Kumbhani: To your point about ... You use a very interesting word, the last nail. That's actually how Dr Hochman addressed her editorial. She wrote a really nice editorial- Dr Gabriel Steg: The leading expert in the field. Dr Dharam Kumbhani: And so, I'm interested in your thoughts. The use of balloon pumps for shock, there's a discrepancy between the American guidelines and the European guidelines. Last year the European guidelines were updated. It is really such a practice changing guideline in that it now lists routine use of balloon pumps in cardiogenic shock- Dr Gabriel Steg: Class III. Dr Dharam Kumbhani: -as a class III indication. Going through training, that was all you had when someone came in with shock, you would throw in a balloon pump. So that's really quite a practice changing event. Dr Gabriel Steg: Yeah. These investigators are embarking on new studies with ECMO and I think it's going to be fascinating to see whether ECMO, which also gets increasingly used worldwide, whether there is evidence to acutely support or not whether this is useful. I think they are doing the proper thing. They are doing the right thing, randomized trials. And we could commend them because these are really difficult trials. Dr Carolyn Lam: Absolutely. Dr Gabriel Steg: In the acute MI setting, shock patients, ECMO, IABP, that's really difficult. They are brave investigators, they are good investigators, and I think they provided the community with a clear answer. Dr Carolyn Lam: And exactly the kind of papers that we like publishing at circulation, isn't it? Now what about the door-to-unload? Dr Gabriel Steg: That is actually a good segue with door-to-unload because if we can't properly treat shock once it's there, can we do something to prevent shock? Can we do something to preserve myocardium? One of the experimental findings that is very clear is that if you unload experimental myocardial infarction, if you unload the left ventricle you reduce infarct size. Dr Gabriel Steg: So, investigators have been trying to translate this experimental finding into the clinical arena using the Impella device. There's enormous interest, particularly in North America for Impella use in acute MI patients with larger infarcts with the idea that if you can unload the left ventricle, you might be able to mitigate the extent of the myocardial infarction, and therefore avoid cardiogenic shock and probably improve prognosis. Although this is a very attractive theoretical concept, it still deserves to be tested. And so, if you want to test it you have to unload the ventricle as soon as possible, ideally before reperfusion, which means that you're going to have to delay reperfusion for the time of implanting the device and unloading the ventricle. And so what the investigators did in this trial is to study whether delaying proposedly by 30 minutes reperfusion, to unload the ventricle for 30 minutes prior to reperfusion, was feasible and reasonably safe. It's a small trial. It's really a pilot trial. By no means does it test the proof of concept of the device or the theoretical issue, but it shows that it's feasible. There doesn't seem to be a massive increase in total time to reperfusion because just by change the group that was not delayed had a longer time to PCI, so eventually things are sort of evening out. They looked at MRI size of infarcts at follow-up. There was no obvious difference, but of course it could still be tied to errors. We're not totally sure about this, but it certainly paves the way for doing a proper proof of concept randomized trial, testing unloading versus no unloading with a true control group. And I think that's what investigators are looking forward, but I understand there's immense interest for this concept in international community, particularly in the United States and I'm quite curious to see what this future trial will look like and what the results will be. Dr Carolyn Lam: Yeah, indeed. Gabriel, I noticed you were very careful to frame it, to say what the trial was trying to address and what it wasn't. And there's been quite a bit of buzz after that. Do you agree with everything Gabriel has said and what have you heard? Dr Dharam Kumbhani: I think he was incredibly eloquent in outlining the premise of the trial and what it really showed. I think the one thing that ... And this was brought up in the very nice editorial by Dr Patel from Duke as well, is it would've been really nice to have a control arm which didn't have any unloading. Because these are not patients with shock, that just directly had primary PCI. And then comparing infarct size. So, I think that was one of the pieces of information that would've been helpful to then put this in perspective. When you have an infarct size of 8% or 10%, how does that compare in the same patient population in their testing? You're absolutely right about the need to do difficult trials like this, where a lot of times it's just assumed to be true and is embraced in clinical practice. As I gave the example about the balloon pump earlier, where as a Fellow you saw someone in shock and your reflex was to put in a balloon pump. And so, I think testing these very difficult patient scenarios, as well as just in terms of trial execution, it's amazing to have two trials on that. Dr Gabriel Steg: If I may come back to this? Dr Carolyn Lam: Yes. Dr Gabriel Steg: It's funny because we've been using the IABP for years, thinking this is what we should do in shock. Now our German colleagues have proven that IABP doesn't work. So a lot of investigators have reverted, saying "Well, we should use Impella." But where is the evidence showing that Impella is beneficial? Dr Dharam Kumbhani: That's right. Dr Carolyn Lam: That's right. Dr Gabriel Steg: We have none, so I think that's a trial that deserves to be done. Dr Dharam Kumbhani: And ECMO. Yeah, exactly. Dr Carolyn Lam: Yeah, ECMO. Exactly. And, you know, going back to door-to-unload, it's important to prove safety in order to go to the next step, which is exactly how you frame- Dr Gabriel Steg: I think it shouldn't be over interpreted. Dr Carolyn Lam: That's how it should be, exactly, received by the community. So that's great. Now let's switch gears a bit. Sana, in EP world, the EP guided noninvasive radio ablation of VT. Fascinating stuff. What are your thoughts? Dr Sana Al-Khatib: I absolutely agree, definitely. This was a phase two study that the authors did. They enrolled 19 patients, so it was a small study, but it was really helpful. Remember, there's a major clinical need there. These are patients who have an ICD, who have recurring ventricular tachycardia, that have been treated with at least one antiarrhythmic medication, at least one catheter ablation procedure, and then what do you do with those patients? This is actually a clinical scenario that comes up frequently and we absolutely need to be looking for more therapies for those patients. So that's what that study was about, trying to explore new ways to treat these patients. To be able to do it noninvasively, I think is fascinating. That's what ... They enrolled these patients. Patients had to have failed these treatments, antiarrhythmic medications, prior catheter ablation, and they underwent noninvasive imaging to really localize the source of the ventricular tachycardia, where it's coming from, and then they subjected them to stereotactic body radiotherapy to ablate those sources of ventricular tachycardia. And, of course, the results were fascinating because they showed on the effectiveness side that this seemed to be very effective because if you look at the reduction in the burden of ventricular tachycardia, and a couple of their patients actually had significant PVCs and PVC induced cardiomyopathy, there was a significant reduction in the rates of these arrhythmias in these patients with this intervention, which was great to see. In fact, to be specific, about 94% of these patients, so 18 out of the 19, had significant benefit. And in about 89% of the patients there was more than 75% reduction in the arrhythmia. So these are actually really interesting findings, especially in a patient population where we really don't have other options. Now of course you're going to ask me about the safety. What are the safety concerns? Of course, this was a primary endpoint for the authors. They did look at safety up to 90 days and they found that there were two significant adverse events that occurred in those 90 days. One was heart failure and one was pericarditis. The concern, of course, with radiation is what else can we expect especially if you follow the patients longer? So certainly we need more data. The authors acknowledged that beautifully and I think their intent is to launch a multi-center randomized clinical trial. I don't know if it will be randomized, but at least a multi-center clinical trial to see if they can replicate those findings. So that was very interesting to see. Dr Carolyn Lam: Yeah it was. Thanks, that was really exciting. So, some exciting trials in my world of cardiometabolic disease too, and I want to highlight two. The CARMELINA trial and the CAMELLIA-TIMI 61. First the CARMELINA trial. This was a secondary analysis of CARMELINA and this was ... CARMELINA, if I can remind everyone, is a cardiovascular outcomes trial, randomizing about 7000 patients with type 2 diabetes and atherosclerotic cardiovascular disease, and/or chronic kidney disease. Randomizing them to the DPP-4 inhibitor linagliptin 5 mg a day versus placebo, following up for a median of about two years. We know that type 2 diabetic patients are at risk of heart failure and there's always been a bit of a question mark when it comes to DPP-4 inhibitors and their risk for heart failure. And so this secondary analysis looks specifically at the hospitalization for heart failure and related events in CARMELINA. The important thing is that all these were prospectively centrally adjudicated events, and this was a pre-specified post hoc analysis. And the summary of it all is that linagliptin was not associated with an increased risk of hospitalization for heart failure or the composite of cardiovascular death in hospitalization or the related outcomes. Importantly, the authors did also sensitivity analyses and interaction analyses to show that the results were consistent whether or not patients had a history of heart failure, which was in 27% of patients, regardless of the baseline ejection fraction that was measured within a year of starting the drug, and also regardless of renal function. So EGFR or urinary albumin to creatinine ratio. This is really important because this trial adds to the growing perhaps understanding of DPP-4 inhibitor heart failure risk. The whole question mark actually came with SAVOR TIMI and that was saxagliptin. But since then there's been three other trials that have showed no heart failure risk. EXAMINE, TECOS, and now CARMELINA. So, an important addition and I think it should reassure us. And then from diabetes and heart failure risk, which is always very hot, but now obesity. The CAMELLIA-TIMI 61 trial looked at renal outcomes in this trial. Now what was this trial? It was actually testing lorcaserin, and that is a selective serotonin 2C receptor agonist, in about 12,000 obese or overweight patients. Basically, the primary results showed that it did not increase any ... It met it's CV safety outcomes with weight loss and so on. But this time they looked at renal outcomes. Because obesity has been known to be associated with hyperfiltration of the kidneys, you get albuminuria and it's apparently worsening of kidney disease. So what we need to know is pharmacological weight loss going to be associated with improved renal outcomes? And basically, that is what CAMELLIA-TIMIA 61 showed. Their renal outcomes were new or persistent albuminuria and then the standard doubling of EGFR or end-stage renal failure, renal transplant or renal death. And that was improved by lorcaserin. Along with that, there was the anticipated reduction in weight, HbA1c, and BP. It does look like, from these late breaking results that we have another tool in our toolbox. Dr Sana Al-Khatib: And for the clinicians out there, which patients should they be thinking to use this medication in? What kind of obesity are we talking about? At what point do you introduce that? Dr Carolyn Lam: This is common garden, just defined by BMI that was above 27. And I don't think they're saying to use it in patients with renal dysfunction, but to sort of say to look and see whether weight loss also associates with renal function improvement, and it does. It's reassuring. Dr Sana Al-Khatib: Yeah, okay. Dr Carolyn Lam: And then ... Okay, let's round up with that last trial. A very interesting one because it's pragmatic mobile health and wellness. Tell us. Dr Dharam Kumbhani: It's really a monumental effort. This is ... I'll be brief, but it's really a phenomenal trial from an epi standpoint and implementation standpoint. This is from India. It was coordinated by the Center for Chronic Disease Control and the Public Health Foundation of India where, as everyone knows, India is now the diabetes capital of the world and chronic diseases have very quickly overtaken other infectious causes as the number one cause of mortality and morbidity. This was a big undertaking, really collaboration from three continents, but it was a community based plus a randomized trial. They had 40 community health centers and what they were trying to see is primarily for hypertension and diabetes. That if you implemented a structure and typically using this mWELLCARE tool, which is basically an electronic medical records storage facility and then it also has inbuilt clinical decision support. And really for hypertension and diabetes management, but also, they had tobacco and alcohol screening, abuse screening, and also for depression. So what they really wanted to do ... A very ingenious endeavor and they try to see if doing this systematically on a clustered randomized fashion if that would actually influence patient outcome. They had a little over 3000 patients and they followed them for 12 months. Unfortunately, the trial, itself, as far as the primary endpoint, which was change in systolic blood pressure and hemoglobin A1c, they had pretty significant reductions in both arms, about 12 to 13 millimeters, which is amazing from a population health standpoint, in both arms not statistically significant, and in hemoglobin A1c also by 0.5% in both arms. Just suggesting that having this more frequent interactions with the medical health system, itself, was driving a lot of this benefit. So although the trial, itself, was negative for the primary endpoint, I think it's a huge step forward for the management of chronic disease epidemiology and burden in developing countries. Dr Gabriel Steg: Neutral. Dr Carolyn Lam: Ah, true. Dr Dharam Kumbhani: Fair point. Dr Carolyn Lam: We've discussed this whole array of seven trials and they are difficult trials. I mean, talk about another difficult type of trial to do, cluster randomized pragmatic trial. It's amazing the breadth of simultaneous publications we've had this year. Thanks again to everyone for introducing this and thank you for joining us today.
Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF. Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications. MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acute settings. Long term devices such as implantable left ventricular assist devices (LVADs) e.g. Heartmate II® & 3®, Heart ware HVAD® are implanted as ‘Bridge to transplant’ (BTT) or ‘Destination therapy’ (DT) usually in patients ‘sliding’ on inotropes when they are transplant eligible (BTT) or ineligible (DT) respectively. Ventricular assist devices have traditionally been developed for left ventricular support in case of severe left heart or biventricular dysfunction. Historically, right ventricular (RV) dysfunction following LVAD implantation or as a component of biventricular dysfunction was managed with either medical therapy, temporary VADs (i.e. ECMO configuration with continuous flow centrifugal pumps like CentriMag®, Rotaflow ®) or occasionally with LVADs placed on the right side. Recently the Impella RP® and ProtekDuo®, percutaneously placed pumps with inflow in the inferior vena cava & right atrium respectively and outflow in pulmonary artery, have become available as less invasive options, for short term RV support. The Syncardia® is the only approved total artificial heart system currently in use; however various biventricular, total heart systems (e.g. BiVACOR®) in development show promise. Mechanical circulatory devices provide attractive, viable, physiologically plausible ventricular support options that can be used effectively in carefully selected patients.
Impella® placement
Commentary by Dr. Valentin Fuster
Pete McCanny gives a talk on the cutting edge management of cardiogenic shock and challenges the conventional approach to mechanical support.
In this episode we explore two very different applications of the Impella® device - a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve. The post EDECMO 32 – Archimedes Screw: Is Impella the Future of Mechanical Circulatory Support? appeared first on ED ECMO.
Guest: Michael P. Siegenthaler, MD Host: Matthew J. Sorrentino, MD, FACC, FASH Dr. Michael Siegenthaler, associate professor of surgery at the University of Pittsburgh School of Medicine, describes the Impella 2.5 system: a percutaneously-placed ventricular-assist device, now approved for high risk coronary interventions, that has earned the moniker, 'world's smallest heart pump.' Dr. Matthew Sorrentino hosts.
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