Research Spotlight

Posted February 15th 2019

Rate of major adverse renal or cardiac events with iohexol compared to other low osmolar contrast media during interventional cardiovascular procedures.

Peter McCullough M.D.

Peter McCullough M.D.

McCullough, P. A., T. M. Todoran, E. S. Brilakis, M. P. Ryan and C. Gunnarsson (2019). “Rate of major adverse renal or cardiac events with iohexol compared to other low osmolar contrast media during interventional cardiovascular procedures.” Catheter Cardiovasc Interv 93(2): E90-e97.

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OBJECTIVE: This study assessed the rate of major adverse renal or cardiac events (MARCE) when iohexol is used during interventional cardiovascular procedures compared to other low osmolar contrast media (LOCMs). BACKGROUND: Interventional cardiovascular procedures are often essential for diagnosis and treatment, the risk of MARCE should be considered. METHODS: Data were derived from the Premier Hospital Database January 1, 2010 through September 30, 2015. Patient encounters with an inpatient primary interventional cardiovascular procedure with a single LOCM (iohexol, ioversol, ioxilan, ioxaglate, or iopamidol) were included. The primary outcome was a composite endpoint of MARCE, which included: renal failure with dialysis, acute kidney injury (AKI) with or without dialysis, contrast induced AKI, acute myocardial infarction, angina, stent occlusion/thrombosis, stroke, transient ischemic attack, or death. Multivariable regression analysis was performed using the hospital fixed-effects specification to assess the relationship between MARCE and iohexol compared to other LOCMs, while controlling for patient demographics, comorbid conditions and reason for hospitalization. As a sensitivity analysis, direct comparisons of iohexol were made to other LOCMs. RESULTS: A total of 458,091 inpatient encounters met inclusion criteria of which 26% used iohexol and 74% used other LOCMs. Results of multivariable modeling revealed no differences in MARCE rates between iohexol and other LOCMs. When direct comparisons of iohexol vs. ioversol and iopamidol were modeled, no differences in MARCE nor the renal component of MARCE were found. CONCLUSIONS: In this retrospective multicenter study, there were no differences in MARCE events with iohexol compared to other LOCMs during inpatient interventional cardiovascular procedures.


Posted February 15th 2019

Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study.

Michael J. Mack M.D.

Michael J. Mack M.D.

Friedman, D. J., J. G. Gaca, T. Wang, S. C. Malaisrie, D. R. Holmes, J. P. Piccini, R. M. Suri, M. J. Mack, V. Badhwar, J. P. Jacobs, E. D. Peterson, S. C. Chow and J. Matthew Brennan (2019). “Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study.” J Interv Card Electrophysiol Feb 2. [Epub ahead of print].

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PURPOSE: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. METHODS: In a nationally-representative, contemporary cohort (07/2011-06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. RESULTS: In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% (“unprotected” patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. CONCLUSIONS: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).


Posted February 15th 2019

Treatment of Orthostatic Hypotension Due to Autonomic Dysfunction (Neurogenic Orthostatic Hypotension) in a Patient with Cardiovascular Disease and Parkinson’s Disease.

Peter McCullough M.D.

Peter McCullough M.D.

McCullough, P. A. (2019). “Treatment of Orthostatic Hypotension Due to Autonomic Dysfunction (Neurogenic Orthostatic Hypotension) in a Patient with Cardiovascular Disease and Parkinson’s Disease.” Cardiol Ther Jan 9. [Epub ahead of print].

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INTRODUCTION: The prevalence of neurogenic orthostatic hypotension (nOH) increases with age and is associated with autonomic failure in neurodegenerative diseases (e.g., Parkinson’s disease). Symptoms can interfere with daily activities that require standing or walking and can increase risk of falls and related morbidity. Many patients with nOH have or develop cardiovascular comorbidities that can predate nOH symptoms or may arise as a result of autonomic dysregulation. In this report, we describe a complicated case of a patient with cardiovascular disease and Parkinson’s disease who presented with orthostatic symptoms. CASE REPORT: A 78-year-old man with a history of coronary heart disease, class III heart failure, cardiac cachexia, long-standing persistent atrial fibrillation (AF), Hodgkin’s lymphoma, and Parkinson’s disease presented with weakness, dizziness, presyncope, fatigue, and inability to stand. Orthostatic blood pressure (BP) measurements revealed a seated BP of 120/70 mmHg that decreased to 60/40 mmHg upon standing, accompanied by a slight increase in heart rate from 70 to 74 beats per minute. He was diagnosed with nOH and prescribed droxidopa (titrated to 600 mg three times daily). Treatment with droxidopa improved the patient’s ability to stand and his orthostatic BP. CONCLUSION: Droxidopa is approved by the US Food and Drug Administration to treat symptomatic nOH and is not contraindicated in patients with cardiovascular conditions. In this case, treatment with droxidopa improved the patient’s orthostatic tolerance and, importantly, did not change the patient’s rate-controlled AF or his symptoms of class IV heart failure. Because symptoms associated with nOH can be detrimental to patient safety and mobility, it is critical to screen for and treat patients with nOH, even when there are cardiovascular comorbidities. FUNDING: Editorial support and article processing charges were funded by Lundbeck. Plain language summary available for this article.


Posted February 15th 2019

Endoluminal Vacuum Therapy: How I Do It.

Steven G. Leeds M.D.

Steven G. Leeds M.D.

Leeds, S. G., M. Mencio, E. Ontiveros and M. A. Ward (2019). “Endoluminal Vacuum Therapy: How I Do It.” J Gastrointest Surg Jan 22. [Epub ahead of print].

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Perforations and leaks of the gastrointestinal tract are difficult to manage and are associated with high morbidity and mortality. Recently, endoscopic approaches have been applied with varying degrees of success. Most recently, the use of endoluminal vacuum therapy has been used with high success rates in decreasing both morbidity and mortality. Under an IRB-approved prospective registry that we started in July 2013, we have been using endoluminal vacuum therapy to treat a variety of leaks throughout the GI tract. The procedure uses an endosponge connected to a nasogastric tube that is endoscopically guided into a fistula cavity in order to facilitate healing, obtain source control, and aid in reperfusion of the adjacent tissue with debridement. Endoluminal vacuum therapy has been used on all patients in the registry. Overall success rate for healing the leak or fistula is 95% in the esophagus, 83% in the stomach, 100% in the small bowel, and 60% of colorectal cases. The purpose of this report is to review the history of endoluminal wound vacuum therapy, identify appropriate patient selection criteria, and highlight “pearls” of the procedure. This article is written in the context of our own clinical experience, with a primary focus on a “How I Do It” technical description.


Posted February 15th 2019

Early vs late oral nutrition in patients with diabetic ketoacidosis admitted to a medical intensive care unit.

Kirill Lipatov, M.D.

Kirill Lipatov, M.D.

Lipatov, K., K. K. Kurian, C. Shaver, H. D. White, S. Ghamande, A. C. Arroliga and S. Surani (2019). “Early vs late oral nutrition in patients with diabetic ketoacidosis admitted to a medical intensive care unit.” World J Diabetes 10(1): 57-62.

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BACKGROUND: Diabetic ketoacidosis (DKA) has an associated mortality of 1% to 5%. Upon admission, patients require insulin infusion and close monitoring of electrolyte and blood sugar levels with subsequent transitioning to subcutaneous insulin and oral nutrition. No recommendations exist regarding the appropriate timing for initiation of oral nutrition. AIM: To assess short-term outcomes of oral nutrition initiated within 24 h of patients being admitted to a medical intensive care unit (MICU) for DKA. METHODS: A retrospective observational cohort study was conducted at a single academic medical center. The patient population consisted of adults admitted to the MICU with the diagnosis of DKA. Baseline characteristics and outcomes were compared between patients receiving oral nutrition within (early nutrition group) and after (late nutrition group) the first 24 h of admission. The primary outcome was 28-d mortality. Secondary outcomes included 90-d mortality, MICU and hospital lengths of stay (LOS), and time to resolution of DKA. RESULTS: There were 128 unique admissions to the MICU for DKA with 67 patients receiving early nutrition and 61 receiving late nutrition. The APACHE (Acute Physiology and Chronic Health Evaluation) IV mortality and LOS scores and DKA severity were similar between the groups. No difference in 28- or 90-d mortality was found. Early nutrition was associated with decreased hospital and MICU LOS but not with prolonged DKA resolution, anion gap closure, or greater rate of DKA complications. CONCLUSION: In patients with DKA, early nutrition was associated with a shorter MICU and hospital LOS without increasing the rate of DKA complications.