Research Spotlight

Fathima, S. and W. C. Roberts (2019). “Comparison of Clinical and Morphologic Findings in Patients With Cardiac Sarcoidosis Severe Enough to Warrant Heart Transplantation in Those With -vs- Those Without Non-Caseating Granulomas in the Explanted Heart (Burnt-Out Sarcoid).” Am J Cardiol 124(4): 599-603.

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Can cardiac sarcoidosis with heart failure severe enough to warrant orthotopic heart transplantation (OHT) be present without non-caseating granulomas in the explanted heart? The objective is to compare clinical and morphological features in patients with cardiac sarcoidosis severe enough to warrant OHT with -vs-without non-caseating granulomas in the explanted heart. The study was conducted at Baylor University Medical Center in Dallas, Texas. From a total of 671 explanted hearts examined from 1993 to 2018, twenty-five (4%) had gross morphologic features characteristic of cardiac sarcoidosis. At the time of OHT, the patients ranged in age from 50 to 69 years [mean 57]. Cardiac sarcoidosis was diagnosed before OHT in 3 (12%) patients, by percutaneous biopsy of the heart in 2 patients and by histologic examination of the “left ventricular core” in 1 patient who had a left ventricular assist device inserted, and, by examination of the native heart after OHT in the remaining 22 (88%) patients. Of the 25 patients, 16 (64%) had typical sarcoid non-caseating granulomas in the explanted heart, and 9 (36%) had no granulomas in the explanted heart. Comparison of certain clinical and morphologic features in the group with -vs- the group without cardiac granulomas showed no significant differences. In conclusion, of patients with cardiac sarcoidosis severe enough to warrant OHT, some have typical non-caseating granulomas in the explanted heart and some do not. The clinical and gross morphologic features of those with and those without cardiac granulomas are similar.

Rodes-Cabau, J., K. A. Ellenbogen, A. D. Krahn, A. Latib, M. Mack, S. Mittal, G. Muntane-Carol, T. M. Nazif, L. Sondergaard, M. Urena, S. Windecker and F. Philippon (2019). “Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement: JACC Scientific Expert Panel.” J Am Coll Cardiol 74(8): 1086-1106.

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Despite major improvements in transcatheter aortic valve replacement (TAVR) periprocedural complications in recent years, the occurrence of conduction disturbances has not decreased over time and remains the most frequent complication of the procedure. Additionally, there has been an important lack of consensus on the management of these complications, which has indeed translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients along with major differences between centers and studies in pacemaker rates post-TAVR. There is therefore an urgent need for a uniform strategy regarding the management of conduction disturbances after TAVR. The present expert consensus scientific panel document has been formulated by a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons as an initial attempt to provide a guide for the management of conduction disturbances after TAVR based on the best available data and group expertise.

Elmets, C. A., H. W. Lim, B. Stoff, C. Connor, K. M. Cordoro, M. Lebwohl, A. W. Armstrong, D. M. R. Davis, B. E. Elewski, J. M. Gelfand, K. B. Gordon, A. B. Gottlieb, D. H. Kaplan, A. Kavanaugh, M. Kiselica, D. Kivelevitch, N. J. Korman, D. Kroshinsky, C. L. Leonardi, J. Lichten, N. N. Mehta, A. S. Paller, S. L. Parra, A. L. Pathy, E. A. Farley Prater, R. N. Rupani, M. Siegel, B. E. Strober, E. B. Wong, J. J. Wu, V. Hariharan and A. Menter (2019). “Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy.” J Am Acad Dermatol 81(3): 775-804.

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Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 3.2% of the world’s population. In this section of the guidelines of care for psoriasis, we will focus the discussion on ultraviolet (UV) light-based therapies, which include narrowband and broadband UVB, UVA in conjunction with photosensitizing agents, targeted UVB treatments such as with an excimer laser, and several other modalities and variations of these core phototherapies, including newer applications of pulsed dye lasers, intense pulse light, and light-emitting electrodes. We will provide an in-depth, evidence-based discussion of efficacy and safety for each treatment modality and provide recommendations and guidance for the use of these therapies alone or in conjunction with other topical and/or systemic psoriasis treatments.

Elkayam, U., A. Schafer, A. Chieffo, A. Lansky, S. Hall, Z. Arany and C. Grines (2019). “Use of Impella heart pump for management of women with peripartum cardiogenic shock.” Clin Cardiol Aug 22. [Epub ahead of print].

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BACKGROUND: Percutaneous mechanical circulatory support (MCS), such as the Impella heart pump is a valuable option for cardiogenic shock (CS), although the use of Impella in CS due to peripartum cardiomyopathy (PPCM) is limited. OBJECTIVE: To assess outcomes in women with PPCM supported with an Impella device from the global catheter-based ventricular assist device (cVAD) Registry. METHODS AND RESULTS: A total of 15 women with PPCM supported with Impella devices between November 2008 and October 2015 were included. Of the 15 women, five were treated at Hannover medical school and have been reported previously, the rest were managed at various US hospitals. The mean age was 30.0 +/- 7.34 years, eight women were Caucasian, and seven were African-American. The occurrence of PPCM was post-delivery in eight (53.3%), at delivery in one (6.7%), and during gestation in four women (26.7%). At admission, all women had severe heart failure with a mean ejection fraction of 14.7 +/- 6% and 13 women (86.7%) presented with CS. Prior to Impella, 100% were mechanically ventilated, 79% received inotropes/vasopressors, 20% supported with IABP, and 27% received veno-arterial extracorporeal membrane oxygenation (VA ECMO) during Impella support. Two women (13.3%) died, and 13 (87.7%) survived to discharge. Eight women (53.3%) had a recovery of native heart function and six (40%) were bridged to durable left ventricular assist device (LVAD). CONCLUSION: MCS with Impella devices can be successfully used as a bridge to early improvement, heart recovery, or successful implantation of durable LVAD in women with PPCM complicated by severe LV dysfunction.

El-Ansary, D., T. K. LaPier, J. Adams, R. Gach, S. Triano, M. A. Katijjahbe, A. Hirschhorn, S. Mungovan, A. Lotshaw and L. P. Cahalin (2019). “An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy.” Phys Ther Sep 2. [Epub ahead of print].

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Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contributes to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. In this perspective paper, we propose that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. We advocate a clinical paradigm shift that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.