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Seminars in Ultrasound, CT, and MR Feb 2024Acute pericardial conditions, such as tamponade, are often rapidly progressive and can become life-threatening without timely diagnosis and intervention. In this review,... (Review)
Review
Acute pericardial conditions, such as tamponade, are often rapidly progressive and can become life-threatening without timely diagnosis and intervention. In this review, we aim to describe bedside ultrasonographic evaluation of the pericardium and diagnostic criteria for tamponade, identify confounders in the diagnosis of pericardial tamponade, and delineate procedural details of ultrasound-guided pericardiocentesis.
Topics: Humans; Pericardial Effusion; Point-of-Care Systems; Pericardium; Cardiac Tamponade; Echocardiography
PubMed: 38056788
DOI: 10.1053/j.sult.2023.12.009 -
European Heart Journal. Acute... Jul 2023Pericardial effusions can result in acute haemodynamic compromise and require rapid intervention. Understanding pericardial restraint is essential to determine the... (Review)
Review
Pericardial effusions can result in acute haemodynamic compromise and require rapid intervention. Understanding pericardial restraint is essential to determine the approach to newly identified pericardial effusions in the intensive care unit. As pericardial effusions stretch the pericardium, the pericardial compliance reserve is eventually exhausted, with an exponential rise in compressive pericardial pressure. The severity of pericardial pressure increase depends on both the rapidity and volume of pericardial fluid accumulation. This increase in pericardial pressure is reflected in an increase in measured left- and right-sided 'filling' pressures, but paradoxically left ventricular end-diastolic volume (the true left ventricular preload) is decreased. This uncoupling of filling pressures and preload is the hallmark of pericardial restraint. When this occurs acutely from a pericardial effusion, rapid recognition and pericardiocentesis can be lifesaving. In this review, we will discuss the haemodynamics and pathophysiology of acute pericardial effusions, provide a physiological guide to determine the need for pericardiocentesis in acute care, and discuss important caveats to management.
Topics: Humans; Pericardial Effusion; Pericarditis, Constrictive; Pericardiocentesis; Pericardium; Hemodynamics; Cardiac Tamponade
PubMed: 37202863
DOI: 10.1093/ehjacc/zuad050 -
Medicina Intensiva Dec 2023The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of... (Review)
Review
The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.
Topics: Humans; Ultrasonography, Interventional; Ultrasonography; Critical Care; Point-of-Care Systems; Intensive Care Units
PubMed: 38035918
DOI: 10.1016/j.medine.2023.05.016 -
JACC. Clinical Electrophysiology Jul 2023Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation (HA) results in better outcomes in patients with persistent atrial fibrillation (persAF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure.
OBJECTIVES
The purpose of this study was to compare the effectiveness and safety of HA with CA in a prospective, superiority, unblinded, randomized controlled trial.
METHODS
Forty-one ablation-naive patients with (long-standing)-persAF were randomized to HA (n = 19) or CA (n = 22) and received pulmonary vein isolation, posterior left atrial wall isolation and, if needed, a cavotricuspid isthmus ablation. The primary efficacy endpoint was freedom from any atrial tachyarrhythmia >5 minutes off antiarrhythmic drugs after 12 months. The primary and secondary safety endpoints included major and minor complications and the total number of serious adverse events.
RESULTS
After 12 months, the freedom of atrial tachyarrhythmias off antiarrhythmic drugs was higher in the HA group compared with the CA group (89% vs 41%, P = 0.002). There was 1 pericarditis requiring pericardiocentesis and 1 femoral arteriovenous-fistula in the HA group. In the CA arm, 1 bleeding from the femoral artery occurred. There were no deaths, strokes, need for pacemaker implantation, or conversions to sternotomy, and the number of (serious) adverse events was comparable between groups (21% vs 14%, P = 0.685).
CONCLUSIONS
Hybrid AF ablation is an efficacious and safe procedure and results in better outcomes than catheter ablation for the treatment of patients with persistent AF. (Hybrid Versus Catheter Ablation in Persistent AF [HARTCAP-AF]; NCT02441738).
Topics: Humans; Atrial Fibrillation; Treatment Outcome; Prospective Studies; Anti-Arrhythmia Agents; Catheter Ablation
PubMed: 36752455
DOI: 10.1016/j.jacep.2022.12.011 -
Pediatric Dermatology 2023Capillary malformation-arteriovenous malformation (CM-AVM) is characterized by multifocal fast-flow capillary malformations, sometimes with arteriovenous...
BACKGROUND
Capillary malformation-arteriovenous malformation (CM-AVM) is characterized by multifocal fast-flow capillary malformations, sometimes with arteriovenous malformations/fistulas, skeletal/soft tissue overgrowth, telangiectasias, or Bier spots. Lymphatic abnormalities are infrequently reported. We describe seven patients with CM-AVM and lymphatic anomalies.
METHODS
Following IRB approval, we identified patients with CM-AVM and lymphatic anomalies seen at the Vascular Anomalies Center at Boston Children's Hospital from 2003 to 2023. We retrospectively reviewed records for clinical, genetic, laboratory, and imaging findings.
RESULTS
We found seven patients with CM-AVM and lymphatic abnormalities. Five patients were diagnosed prenatally: four with pleural effusions (including one suspected chylothorax) and one with ascites. Pleural effusions resolved after neonatal drainage in three patients and fetal thoracentesis in the fourth; however, fluid rapidly reaccumulated in this fetus causing hydrops. Ascites resolved after neonatal paracentesis, recurred at 2 months, and spontaneously resolved at 5 years; magnetic resonance lymphangiography for recurrence at age 19 years suggested a central conducting lymphatic anomaly (CCLA), and at age 20 years a right spermatic cord/scrotal lymphatic malformation (LM) was detected. Chylous pericardial effusion presented in a sixth patient at 2 months and disappeared after pericardiocentesis. A seventh patient was diagnosed with a left lower extremity LM at 16 months. Six patients underwent genetic testing, and all had RASA1 mutation. RASA1 variant was novel in three patients (c.1495delinsCTACC, c.434_451delinsA, c.2648del), previously reported in two (c.2603+1G>A, c.475_476del), and unavailable in another. Median follow-up age was 5.8 years (4 months-20 years).
CONCLUSION
CM-AVM may be associated with lymphatic anomalies, including pericardial/pleural effusions, ascites, CCLA, and LM.
Topics: Male; Child; Infant, Newborn; Female; Humans; Young Adult; Adult; Child, Preschool; Retrospective Studies; Ascites; p120 GTPase Activating Protein; Capillaries; Arteriovenous Malformations; Arteriovenous Fistula; Pleural Effusion; Lymphatic Abnormalities; Hydrops Fetalis
PubMed: 37767822
DOI: 10.1111/pde.15443 -
Texas Heart Institute Journal Dec 2023Endoscopic ultrasonography-guided transesophageal pericardiocentesis was performed for a posteriorly located effusion not amenable to transthoracic drainage in a...
Endoscopic ultrasonography-guided transesophageal pericardiocentesis was performed for a posteriorly located effusion not amenable to transthoracic drainage in a 58-year-old woman with a history of recurrent breast adenocarcinoma who presented with dyspnea. The patient had a pericardial effusion that resulted in cardiac tamponade. Transthoracic pericardiocentesis was unsuitable because of the posterior location of the effusion. Pericardiocentesis via the transesophageal route was performed. The pericardial sac was punctured with a 19-gauge needle, and 245 mL of pericardial fluid were aspirated, resulting in the resolution of the tamponade physiology. Endoscopic ultrasonography-guided transesophageal drainage is a novel and promising therapeutic option for posteriorly located pericardial effusions.
Topics: Female; Humans; Middle Aged; Pericardial Effusion; Pericardiocentesis; Cardiac Tamponade; Pericardium; Needles
PubMed: 38087478
DOI: 10.14503/THIJ-23-8230 -
Cureus Oct 2023Minoxidil-induced pleuro-pericardial effusion is a diagnosis of exclusion after evaluation for other known causes of pericardial effusion. When complicated by cardiac...
Minoxidil-induced pleuro-pericardial effusion is a diagnosis of exclusion after evaluation for other known causes of pericardial effusion. When complicated by cardiac tamponade, prompt pericardiocentesis and discontinuation of minoxidil can be lifesaving. We report a rare case of minoxidil-induced pleuro-pericardial effusion with tamponade in a patient with end-stage renal disease (ESRD) on hemodialysis who improved with pericardiocentesis and drug withdrawal.
PubMed: 37927730
DOI: 10.7759/cureus.46416 -
The Journal of Invasive Cardiology Jan 2024Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
OBJECTIVES
Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
METHODS
We examined the clinical and angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke.
RESULTS
Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 [103,204] vs 110 [72,160] min; P less than .01) and higher air kerma radiation dose (2.3 [1.3, 3.6] vs 2.0 [1.1, 3.5] Gray; P less than .01).
CONCLUSIONS
Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.
Topics: Humans; Hospital Mortality; Percutaneous Coronary Intervention; Echocardiography; Stroke; Hemodynamics
PubMed: 38224295
DOI: 10.25270/jic/23.00106 -
European Journal of Trauma and... Oct 2023Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and...
Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.
INTRODUCTION
Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.
MATERIAL AND METHODS
The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.
RESULTS
This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.
CONCLUSIONS
Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
Topics: Humans; Anesthesiology; Critical Care; Heart Arrest; Resuscitation; Thoracotomy
PubMed: 37430174
DOI: 10.1007/s00068-023-02271-3 -
The American Journal of Cardiology Aug 2023Sex-based disparities in outcomes are reported for various cardiovascular procedures. This study aimed to assess the difference in outcomes in patients who underwent...
Sex-based disparities in outcomes are reported for various cardiovascular procedures. This study aimed to assess the difference in outcomes in patients who underwent WATCHMAN device implant based on sex. Patients who underwent WATCHMAN device placement, from 2016 to 2018, were identified from the National Inpatient Sample database. The primary outcome was inpatient mortality, and the secondary outcomes were the length of stay (LOS), hospitalization cost (HOC), and periprocedural complications. A logistic regression model was built to perform an adjusted analysis for the outcomes. A total of 12,327 patients underwent WATCHMAN device placement. Female patients were older and more likely to have hypertension (p <0.01) and less likely to have peripheral arterial disease (5.6 vs 7.2, p <0.01), chronic kidney disease (21% vs 26%, p <0.01), and diabetes (18% vs 20%, p = 0.03) and were also at a higher risk for certain periprocedural complications, including pericardiocentesis and anemia requiring blood transfusion (p <0.01 for all). In the unadjusted analysis, the female sex was associated with longer LOS (1.5 vs 1.3 days, p <0.01) and inpatient mortality (0.23 vs 0.10, p = 0.05). The HOC was numerically higher in women but statistically nonsignificant ($120,791 vs $118,554, p = 0.1). In the stepwise, backward, multivariate regression analysis, the female sex was an independent risk factor for higher LOS (1.5 vs 1.3 days, p <0.01, 95% confidence interval 1.3 to 1.4) after adjusting for potential confounders. The inpatient mortality and HOC were similar between 2 groups after adjusting for potential cofounders in the multivariate regression analysis. Our study suggests that the female sex is an independent risk factor for longer LOS among patients hospitalized for WATCHMAN device placement.
Topics: Humans; Female; Treatment Outcome; Retrospective Studies; Risk Factors; Hospitalization; Length of Stay
PubMed: 37352665
DOI: 10.1016/j.amjcard.2023.05.037