Research Article
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Introduction: Unfractionated heparin (UFH) has been the standard anticoagulant for cardiac surgery involving cardiopulmonary bypass (CPB) circuits since 1953. However, there is no universally accepted method for determining the most appropriate dose to achieve the desired activated clotting time (ACT) of at least 480 seconds, or an agreed method for determining the appropriate dose and timing of protamine for heparin reversal.
Methods: A technique for determining an initial heparin dose to achieve a desired ACT was developed for catheter ablation cases in patients with atrial fibrillation. This method also enabled the estimation of an appropriate dose of protamine for reversing the active heparin at the end of the procedure. We evaluated this approach in cardiac bypass cases with additional information being provided by the use of viscoelastic testing.
Results: The method used enabled a single dose of heparin to be found that achieved an ACT of more than 480 seconds in over 82% of cases. A single dose of protamine was effective in reversing the heparin effect after cessation of bypass and patient rewarming in 88.89% of cases.
Conclusion: This study presents a promising, cost-effective approach to managing heparin therapy during coronary bypass (CBP) surgery. Our approach enables an appropriate initial heparin dose to be estimated and determination of a dose of protamine that can be given to adequately reverse active heparin at the end of the procedure, after warming and replacement of pump blood.
Case Report
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Rationale: Drug-inducing adverse effects may be critical and fatal. There is a reported serious cardiovascular (CV) presentation with sildenafil. Mitral stenosis (MS) is the most common cause of valvular atrial fibrillation (AF) and flutter. Brugada syndrome (BrS) is a genetic disorder with abnormal electrical activity within the heart that carries a higher risk for ventricular fibrillation and sudden death. Hiatal hernia is a herniation of intra-abdominal contents into the thorax. There is a durable relationship between COVID-19 infection and ischemic heart disease.
Patient concerns: A 53-year-old, married Egyptian male teacher, mechanically replaced mitral valve (MV) patient was presented to the physician outpatient clinic with intermittent angina within two weeks’ of post-oral sildenafil tablets and COVID-19 pneumonia.
Diagnosis: High lateral ischemia and passed sildenafil-inducing inferior infarction with variable atrial fibro-flutter block, alternative right bundle branch block (RBBB) beat with type II BrS in mechanically replaced MV with recent hiatus hernia and COVID pneumonia.
Interventions: Cardiothoracic surgery, chest X-ray, electrocardiography, echocardiography, and oxygenation.
Outcomes: There is a good outcome despite numerous noteworthy serious risk factors.
Lessons: High lateral ischemia, passed inferior myocardial infarction (MI), variable atrial fibro-flutter block, RBBB beat, BrS, hypocalcemia, recent hiatus hernia, and COVID pneumonia in the mechanically replaced MV are a serious constellation of risk factors. Alternative RBBB beat with type II BrS is newly described. BrS may be transient. Hypocalcemia and Wavy triple ECG sign (Yasser’s sign) are confusing issues for ischemic heart disease.
Research Article
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Predisposition to cardiac disease (CD) is currently becoming a common indication for preimplantation genetic testing (PGT). It provides an option for the couplers at risk to avoid the birth of an offspring with a predisposition to CD, as there are no appropriate strategies to prevent CD in the carries of gene mutations predisposing to this condition. The present paper describes the progress in the application of PGT for CD, with its extended application also to carriers of predisposing genes detected through expanded carrier screening (ECS). We present here our experience of 147 PGT cycles for CD, resulting in the birth of 73 children free of predisposing genes to CD, which is a part of our overall PGT series of over one thousand PGT for monogenic disorders (PGT-M). The accumulated experience, presented below, demonstrates considerable progress in using PGT to avoid the birth of children with a genetic predisposition to CD.
Research Article
Withers K*, Raby K, Parker W, German C, Eyadiel L, Hilton T, Goslen K, Green S, Banoian D, Bapat S, Thomas A, Seals A4 and Pisani B
Continuation of Beta Blockers in Patients on Inotrope Therapy: A Counterintuitive Dilemma Read More »
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Introduction: Cardiogenic shock (CS) and acute decompensated heart failure (ADHF) are states of low cardiac output that manifest as tissue hypoperfusion and end-organ damage. Current guidelines do not provide recommendations regarding beta blocker (BB) use in CS. This study sought to analyze the effects of BB continuation on in-hospital mortality among patients admitted with ADHF necessitating inotropic therapy.
Methods: A single-center, retrospective study was conducted in adult patients hospitalized with ADHF requiring inotropes over a three-year period. Patients with CS were stratified based on the Society for Cardiovascular Angiography and Interventions (SCAI) classification of CS and Get With The Guidelines-Heart Failure (GWTG-HF) risk score. BB continuation was assessed at admission and was defined as administration for at least 50% of the hospital stay. A time-to-event analysis framework was implemented using Cox proportional hazards models to analyze the effect of BB continuation on in-hospital mortality.
Results: A total of 449 patients were included in the study. Twelve patients were excluded, as there was insufficient data to calculate the GWTG-HF risk score. A significant mortality benefit was seen with BB continuation in all statistical models. When adjusted for SCAI and GWTG-HF risk score, BB continuation was associated with a 65% reduction in in-hospital mortality [HR 0.35 95% CI 0.19-0.64, p = 0.0008].
Conclusion: In select patients with ADHF resulting in CS, there appears to be a mortality benefit associated with continuation of BB on admission that remains significant after adjustment for severity of CS.
Research Article
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Recent advances in biomedical applications have focused a lot of emphasis on the detection of what could be caused by cardiovascular disease (CVD). The electrocardiogram (ECG), which depicts the electrical activity of the heart, is the foundation for arrhythmia analysis. Different machine learning methods used on ECG datasets have demonstrated excellent performance in detecting arrhythmias. Nevertheless, feature extraction is necessary for machine learning algorithms. Modern deep learning techniques don't require feature extraction because they learn all the parameters simultaneously, in contrast to these techniques. In this study, a 1D convolutional neural network (CNN) approach is presented and tested on the arrhythmia database of the Massachusetts Institute of Technology-Beth Israel Hospital (MIT-BIH). The proposed model, which only has three layers, attained an accuracy of 97.40%.
Case Report
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An 84-year-old man with a Shelhigh Super Stentless valve presented for valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). Given the lack of radiopaque markers and the presence of a non-coronary cusp (NCC) pseudoaneurysm, implant depth was guided by root aortography at the time of balloon aortic valvuloplasty (BAV) using a pigtail in the right coronary cusp (RCC).
Case Report
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Incessant ectopic atrial tachycardia (EAT) is well-known in the electrophysiology world. However, once accompanied by neurological manifestations, hence is a dilemma. We are reporting a 26-year-old male presenting with incessant symptomatic EAT. Once cardioverted, he began to manifest cardiovascular stroke clinical symptoms. Further objective investigation revealed no evidence of cardioembolic stroke. Our aim of this case report is to explore if there is a true correlation between EAT and possible neurological association and open further guidelines related to research.
Case Report
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Calcium channel blocker (CCB)-induced vasoplegia syndrome is an emergent, life-threatening complication that can occur refractory to traditional therapy in the treatment of an acute CCB overdose. We present a case of acute co-ingestion of many prescription medications, including amlodipine and escitalopram. The patient presented with hemodynamic instability that persisted despite conventional therapies. Hydroxycobalamin (HCO) therapy was initiated, resulting in hemodynamic and clinical improvement. We highlight the unique presentation of this case and the potential benefits associated with HCO administration.
Key Points: This case demonstrates the potential benefits of HCO administration in CCB-induced vasoplegia syndrome. Given the significant morbidity and mortality associated with CCB toxicity, HCO may provide considerable benefit in patients with hemodynamic instability refractory to standard treatment modalities.
Research Article
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Heart failure results from the loss of structural integrity of the heart and/or a decrease in the rate of maximal ATP production. In cases of relatively preserved structural integrity, a decrease in ATP production in the mitochondria leads to a decrease in the cardiac stroke volume, thereby increasing the heart rate required to maintain the cardiac output. For many years, the exact location of this defect in the metabolic energy cycle remained elusive. Evidence is presented here to show that it is not a single metabolic substrate involved but rather the heavy isotope of hydrogen 2H, deuterium, that is jamming the ATP nanomotors slowing the rate of ATP production. During the digestion of a meal, the cardiac heart rate is shown to be very sensitive to the level of deuterium contained in the fatty acids recently consumed. During strenuous exercise in the fasting state, the enzyme adipose triglyceride lipase (ATGL) is found to mobilize the highest deuterium triglycerides more rapidly than the healthier lower deuterium triglycerides, converting the adipose tissue into a deuterium-depleted energy pool. This is believed to contribute to the low resting heart rates frequently observed in athletes. In vulnerable individuals, i.e., those weakened by disease(s) or space explorers in a weightless environment, the decreased ability to perform strenuous exercise leads to higher deuterium levels in their adipose tissue compromising their ATP production. In these individuals, maintaining healthy deuterium levels is best achieved by an increased intake of lower deuterium-containing foods.
Clinical Research
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Background: Remote monitoring (RM) for cardiac implantable electronic devices (CIED) is a class 1A recommendation by expert consensus. RM incorporation into CIED management allows for early detection of abnormalities, improved patient satisfaction, and enhanced device clinic efficiency.
Cleveland Clinic Abu Dhabi (CCAD) established the first RM program in the United Arab Emirates in 2015, with over 1000 patients enrolled. We report patient RM compliance as an indicator of the overall benefit of our service, aiming to encourage the widespread application of RM technology in the Middle East and other emerging markets.
Objective: To detail the implementation and efficacy of RM service for CIED patients at CCAD to be modeled after as the standard of care for the region.
Methods: Patients are enrolled in RM before hospital discharge and undergo device and wound checks one week later in the device clinic. Additional patient education is provided at that time. Subsequent follow-up includes routine in-person evaluations as well as scheduled RM transmissions. Patient compliance is measured as the proportion of received RM transmissions in relation to all scheduled transmissions.
Results: A total of 1084 patients were enrolled in RM between December 2015 and May 2022. The overall RM compliance rate at 1-year post-implant was 85%.
Conclusion: Our study shows that the establishment of a large-scale RM program in the Middle East region is feasible and associated with excellent patient participation and compliance. We encourage RM integration as the standard of care for CIED patients in our region and areas of the world where such integration has been lagging.
