Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leading to the novel coronavirus disease 2019 (COVID-19) pandemic was first reported in Wuhan, Hubei Province, China. 1 The first cases emerged in late December 2019 rapidly spreading throughout China and beyond, leading to increasing rates of morbidity and mortality worldwide. 2 SARS-CoV-2 is the seventh member of the coronaviruses family that is known to infect humans. 1 As of May 24, 2020, the number of cases exceeds 5 million worldwide accounting for over 337,000 deaths. 3 The COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) reported in April 2020 that approximately 92% of hospitalized patients with COVID-19 had at least one co-morbid condition. The most common associated conditions with COVID-19 among hospitalized patients are hypertension, obesity, and underlying cardiovascular disease. 4 Chronic immunosuppression accounts for approximately 10% of the patients hospitalized. Given the state

The number of patients with left ventricular assist devices (LVAD) has increased over the years and it is important to identify the etiologies for hospital admission, as well as the costs, length of stay and in-hospital complications in this patient group. Using the National Readmission Database from 2010 to 2015, we identified patients with a history of LVAD placement using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code V43.21. We aimed to identify the etiologies for hospital admission, patient characteristics, and in-hospital outcomes. We identified a total of 15,996 patients with an LVAD, the mean age was 58 years and 76% were males. The most common cause of hospital readmission after LVAD was heart failure (HF, 13%), followed by gastrointestinal (GI) bleed (11.8%), device complication (11.5%), and ventricular tachycardia/fibrillation (4.2%). The median length of stay was 6 days (3–11 days) and the median hospital costs was $12,723 USD. The in-hospital mortality was 3.9%, blood transfusion was required in 26.8% of patients, 20.5% had acute kidney injury, 2.8% required hemodialysis, and 6.2% of patients underwent heart transplantation. Interestingly, the most common cause of readmission was the same as the diagnosis for the preceding admission. One in every four LVAD patients experiences a readmission within 30 days of a prior admission, most commonly due to HF and GI bleeding. Interventions to reduce HF readmissions, such as speed optimization, may be one means of improving LVAD outcomes and resource utilization.

We report a case of a 59-year-old male in post-myocardial infarction cardiogenic shock undergoing left atrial venous arterial extracorporeal membrane oxygenation (LAVA-ECMO) as a bridge to transplantation. The unique feature of this ECMO configuration is use of a single trans-septal cannula to provide biventricular unloading and use of a single arterial access.

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A 65‐year‐old female was transferred with myocardial infarction, three‐vessel coronary artery disease, cardiogenic shock and an intraaortic balloon pump. Given persistent shock, mechanical circulatory support (MCS) was upgraded using a left ventricular hemodynamic support device (Impella CP). The patient was monitored in the catheterization laboratory and serial hemodynamic measures were obtained. Initial hemodynamics showed relative improvement; however, serial assessments demonstrated worsening hemodynamics secondary to right ventricular failure, ultimately requiring a right ventricular hemodynamic support device. The case highlights the rapid changes that can occur with mechanical circulatory support devices and demonstrates the importance of obtaining serial hemodynamics in the cardiac catheterization laboratory.

PURPOSE: Septic shock (SS) is a leading cause of intensive care unit (ICU) morbidity and mortality. It remains unclear what the correlation is between diastolic dysfunction severity and clinical outcomes in SS. Furthermore, whether sepsis causes transient diastolic dysfunction or whether diastolic dysfunction is a preceding condition has never been studied. METHODS:We retrospectively studied 248 consecutive patients who were admitted to the ICU with SS from January 2011 to April 2013. Comprehensive baseline demographic, clinical and echocardiographic data was obtained at time of ICU admission. Multivariable logistic regression model was used to identify independent clinical and systolic/diastolic TTE predictors of mortality during ICU stay. Diastolic dysfunction (DD) was graded using echocardiographic Doppler variables, designated as normal, mild (grade I), moderate (grade II) or severe (grade III) dysfunction. The association between diastolic grade and clinical outcomes was done using Fisher's exact test. A cohort of patients from our initial SS database with prior TTE within one year of ICU admission were then identified. Paired t-test was used to assess for differences in pre versus post-SS echocardiographic parameters. RESULTS:Among the 248 patients (mean age, 64.9 AE 18 years; 51% men), there was 23% mortality in the ICU. Baseline demographics were similar between survivors and deceased patients. Multivariate analysis revealed the following three independent predictors of ICU mortality: ratio of mitral E wave to early diastolic velocity of medial mitral annulus (E/e') (OR: 1.04, 95% CI: 1.0-1.08, p<0.05), APACHE II score (OR: 1.07, 95% CI: 1.0-1.1, p<0.05) and lactate levels (OR: 1.37, 95% CI: 1.2-1.6, p<0.05). 32% had normal diastolic function, 47% had grade I dysfunction and 19% had grade II dysfunction. There was an incremental increase in ICU mortality with higher grades of diastolic dysfunction; however, this trend did not reach significance (p¼0.36). Compared to pre-SS, TTEs during SS demonstrated significantly higher E/e' medial annulus (16.15 AE 12.44 and 21.04 AE 16.35; p ¼ 0.048). There were no other statistically significant differences in diastolic dysfunction parameters.CONCLUSIONS: Elevated E/e', reflection of left ventricular filling pressures, is associated with poor outcomes in SS patients. Severity of diastolic dysfunction by grade appears to correlate with increased early mortality in SS; however, larger sized studies are needed verify the statistical significance of this observed trend. Furthermore, while evidence of pre-existing diastolic dysfunction is found pre SS, we note significant progression of DD as a consequence of SS.CLINICAL IMPLICATIONS: Our study highlights the potential useful role of echocardiography in determining diastolic dysfunction which may be used in the risk stratification of critically ill patients admitted to the ICU with septic shock (SS). Furthermore, it suggests that rather than simply a transient consequence of SS, diastolic dysfunction precedes SS and appe...

The objective of our study was to determine the utility of a baseline high sensitivity cardiac troponin (hs-cTnI) value below the limit of quantitation to rule-out acute myocardial infarction (AMI) in patients presenting to the emergency department (ED) with any suspicious symptoms of a cardiac etiology. We enrolled subjects presenting to the ED with symptoms suspicious for AMI. Blood specimens were collected within 1 hour after a triage electrocardiogram. Cardiac troponin I was measured using the Beckman Coulter Access hs-cTnI assay. The diagnosis of AMI was adjudicated by 2 cardiologists using the Third Universal Definition of AMI and Roche Diagnostics Troponin T Generation 5 assay with all available clinical data at 30 days after presentation. A total of 567 subjects had all data required for data analyses. AMI was diagnosed in 46 (8.1%) patients. Two hundred thirty-two (40.9%) individuals had presentation hs-cTnI results <4.0 ng/L. None of the patients with baseline hs-cTnI <4.0 ng/L had an AMI, yielding a negative predictive value of 100.0% and a sensitivity of 100%, and a good prognosis (no AMIs or cardiac-related deaths at 30 days). In this single-center ED study, a baseline presenting novel hs-cTnI value of <4.0 ng/L effectively ruled out AMI in 40.9% of all patients presenting to the ED and having any symptoms suspicious for AMI. Importantly all patients, not only those with chest pain, and those having symptoms for any duration or those with end-stage renal disease requiring dialysis were included.

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