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Cerebrovascular Accident in a Patient with Left Ventricular Assist Device and Therapeutic INR: Should Left Atrial Appendage Be Routinely Closed?
S120 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 discovered with advanced imaging modalities such as computed tomography (CT) of the chest. Conclusion: Calcified apical aneurysms can develop in patients with ICMP and advanced CHF and should always be looked for before LVAD implantation. Advanced imaging techniques, such as CT of the chest, can help to identify such calcified aneurysms preoperatively and safely tailor surgical plans in these patients.
322 A Case Series of Biopsy-Proven Eosinophilic Myocarditis at a Tertiary Care Center Indra Bole1, Syed Z. Qamer2, Mark Hofmeyer1, Farooq H. Sheikh1, Selma F. Mohammed1; 1MedStar Heart and Vascular Institute, Washington, DC; 2Georgetown University, Washington, DC Background: There is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM. Methods: Two authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/ 2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes. Results: Seven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia. Conclusion: The etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population.
Postoperative (post-op) a-fib can develop in LVAD patients placing them at risk of developing cerebrovascular accident (CVA) from left atrial appendage (LAA) thrombus. We present a case of LVAD patient with a new post-op a-fib who developed embolic CVA from LAA thrombus despite having therapeutic INR. In addition, we discuss whether LAA should be precautionary closed during LVAD implantation to prevent such complication. Case: A 64-year-old female with a medical history of advanced ischemic HFrEF (EF 10-15%) status post-LVAD as DT, postoperative afib, uncontrolled DM II who presented with slurred speech and left-sided weakness. Last known well time was 16 hours ago. CT head showed hypodensity in the right centrum semiovale figure 1A. CT angiogram head showed a filling defect in the right middle cerebral artery figure 1B. The patient was diagnosed with acute embolic ischemic CVA. She did not have a-fib before her LVAD. However, during her postop day 2, she developed a new onset-afib requiring amiodarone and digoxin besides warfarin. She was maintained on therapeutic INR post-LVAD except for a period of sub-therapeutic INR of 14 days that was bridged with LMWH figure 1C. TEE revealed LAA thrombus figure 1D which was identified as the embolic source. Physical therapy (PT) worked with the patient in the hospital and after being discharged. She continued to follow up at the HF clinic with gradual functional improvement. Discussion: The patient’s LDH post-LVAD remained at its post-op range between 603 and 952 U/L without peaking, other acute hemolysis indices were negative, and LVAD did not give any alarm. All of that excluded LVAD thrombus as a culprit and confirmed that the LAA thrombus was the CVA source. It was felt that if LAA closure was done during the patient’s LVAD surgery, it would have prevented her CVA. However, the absence of previous a-fib, embolic CVA, or venous thromboembolic event at the time of surgery did not give the surgical team any hint to consider the LAA closure. Conclusion: Patients with LVAD and therapeutic INR remain at risk of forming a thrombus in the LAA and having cardio-embolic CVA. Pending further research focused on cardio-embolic profiling, the role of LAA closure during LVAD implantation surgery should be considered on a case-to-case basis.
Table. Clinical Characteristics and Outcomes in Patients with Histologically-Proven Acute Eosinophilic Myocarditis
Figure 1. A: CT Head Showing Hypodensity in the Right Centrum Semiovale (Yellow Arrows) Including Acute Ischemic CVA. B: CT Angiography Head Showing a Filling Defect Extending from Right ICA to Right MCA (yellow Arrows) Indicating Thrombotic Occlusion. C: Patient’s INR Levels Between LVAD and CVA, Period of low INR Extending from 11/5 to 11/21 was Bridged with SC LMWH. D: TEE Veiw Showing LAA Thrombus (Asteric) E: Repeated CT Head (after 3 Months) Showing Evolved Hypodensity in the Right Centrum Semiovale Indicating Chronic Ischemic CVA (yellow Arrows). Abbreviations: ACA = Anterior Cerebral Artery, CR = Coumadin Ridge, ICA = Internal Carotid Artery, L = Left, LUPV = Left Upper Pulmonary Vein, LV = Left Ventricle, MCA = Middle Cerebral Artery, PCA = Posterior Cerebral Artery. R = Right, S = Smoke, VA = Vertebral Artery.
324 323 Cerebrovascular Accident in a Patient with Left Ventricular Assist Device and Therapeutic INR: Should Left Atrial Appendage Be Routinely Closed? Mohamad Khaled Soufi1, Patrick T. Roughneen2, Ghannam A. Al-Dossari2, Jaime A. Hernandez-Montfort1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX Introduction: Left ventricular assist device (LVAD) as a destination therapy (DT) is considered one of the main therapeutic strategies in patients with end-stage CHF.
A Novel Clinical Decision Support System for Diagnosis and Treatment of Heart Failure: Concordance with Expert Decision Demir Baykal1, Gorica Malisanovic2, Nirav Raval3; 1Eastside Medical Center, Snellville, GA; 2University of Novi Sad Faculty of Medicine, Novi Sad, Serbia; 3AdventHealth Transplant Institute, Orlando, FL Objectives: Conundrum health care providers and institutions face is how to deliver evidence-based medical care at lower cost to an ever expanding portion of society in need. Translation of clinical studies to daily practice and adoption of national and international guidelines have not met expectations. This disappointing shortfall stems primarily from lack of interface between ever growing and changing vast medical literature and individual patient profile. Concurrently, threats of penalties for
322 A Case Series of Biopsy-Proven Eosinophilic Myocarditis at a Tertiary Care Center Indra Bole1, Syed Z. Qamer2, Mark Hofmeyer1, Farooq H. Sheikh1, Selma F. Mohammed1; 1MedStar Heart and Vascular Institute, Washington, DC; 2Georgetown University, Washington, DC Background: There is limited published literature on acute eosinophilic myocarditis (EM), a rare form of acute myocarditis, wherein eosinophils invade the myocardium with wide-ranging clinical sequalae. We aim to describe our experience in the largest contemporary case series of histologically-proven EM. Methods: Two authors independently reviewed the surgical pathology and autopsy databases for acute EM (01/ 2009 to 12/2017). Only patients with endomyocardial biopsy/autopsy and clinical course consistent with acute EM were included. We abstracted demographic data, comorbidities, clinical diagnostics, and clinical outcomes. Results: Seven patients had acute EM (Table). The average age was 53-years and five subjects were women. The most common etiology of EM was idiopathic. Five patients had peripheral eosinophilia. Three patients had elevated pulmonary capillary wedge pressure and three patients had reduced cardiac output. Six patients were treated with steroids, four of whom received IV pulse dosed steroids. Two patients required intra-aortic balloon pump support, one of whom subsequently underwent durable left ventricular assist device implantation. Two patients died during index hospitalization, one of septic shock and one of refractory ventricular tachycardia. Conclusion: The etiologies, clinical presentation, and course of acute EM varied widely. Prompt diagnosis, treatment with immunosuppression, and circulatory support may reduce cardiovascular mortality in this population.
Postoperative (post-op) a-fib can develop in LVAD patients placing them at risk of developing cerebrovascular accident (CVA) from left atrial appendage (LAA) thrombus. We present a case of LVAD patient with a new post-op a-fib who developed embolic CVA from LAA thrombus despite having therapeutic INR. In addition, we discuss whether LAA should be precautionary closed during LVAD implantation to prevent such complication. Case: A 64-year-old female with a medical history of advanced ischemic HFrEF (EF 10-15%) status post-LVAD as DT, postoperative afib, uncontrolled DM II who presented with slurred speech and left-sided weakness. Last known well time was 16 hours ago. CT head showed hypodensity in the right centrum semiovale figure 1A. CT angiogram head showed a filling defect in the right middle cerebral artery figure 1B. The patient was diagnosed with acute embolic ischemic CVA. She did not have a-fib before her LVAD. However, during her postop day 2, she developed a new onset-afib requiring amiodarone and digoxin besides warfarin. She was maintained on therapeutic INR post-LVAD except for a period of sub-therapeutic INR of 14 days that was bridged with LMWH figure 1C. TEE revealed LAA thrombus figure 1D which was identified as the embolic source. Physical therapy (PT) worked with the patient in the hospital and after being discharged. She continued to follow up at the HF clinic with gradual functional improvement. Discussion: The patient’s LDH post-LVAD remained at its post-op range between 603 and 952 U/L without peaking, other acute hemolysis indices were negative, and LVAD did not give any alarm. All of that excluded LVAD thrombus as a culprit and confirmed that the LAA thrombus was the CVA source. It was felt that if LAA closure was done during the patient’s LVAD surgery, it would have prevented her CVA. However, the absence of previous a-fib, embolic CVA, or venous thromboembolic event at the time of surgery did not give the surgical team any hint to consider the LAA closure. Conclusion: Patients with LVAD and therapeutic INR remain at risk of forming a thrombus in the LAA and having cardio-embolic CVA. Pending further research focused on cardio-embolic profiling, the role of LAA closure during LVAD implantation surgery should be considered on a case-to-case basis.
Table. Clinical Characteristics and Outcomes in Patients with Histologically-Proven Acute Eosinophilic Myocarditis
Figure 1. A: CT Head Showing Hypodensity in the Right Centrum Semiovale (Yellow Arrows) Including Acute Ischemic CVA. B: CT Angiography Head Showing a Filling Defect Extending from Right ICA to Right MCA (yellow Arrows) Indicating Thrombotic Occlusion. C: Patient’s INR Levels Between LVAD and CVA, Period of low INR Extending from 11/5 to 11/21 was Bridged with SC LMWH. D: TEE Veiw Showing LAA Thrombus (Asteric) E: Repeated CT Head (after 3 Months) Showing Evolved Hypodensity in the Right Centrum Semiovale Indicating Chronic Ischemic CVA (yellow Arrows). Abbreviations: ACA = Anterior Cerebral Artery, CR = Coumadin Ridge, ICA = Internal Carotid Artery, L = Left, LUPV = Left Upper Pulmonary Vein, LV = Left Ventricle, MCA = Middle Cerebral Artery, PCA = Posterior Cerebral Artery. R = Right, S = Smoke, VA = Vertebral Artery.
324 323 Cerebrovascular Accident in a Patient with Left Ventricular Assist Device and Therapeutic INR: Should Left Atrial Appendage Be Routinely Closed? Mohamad Khaled Soufi1, Patrick T. Roughneen2, Ghannam A. Al-Dossari2, Jaime A. Hernandez-Montfort1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX Introduction: Left ventricular assist device (LVAD) as a destination therapy (DT) is considered one of the main therapeutic strategies in patients with end-stage CHF.
A Novel Clinical Decision Support System for Diagnosis and Treatment of Heart Failure: Concordance with Expert Decision Demir Baykal1, Gorica Malisanovic2, Nirav Raval3; 1Eastside Medical Center, Snellville, GA; 2University of Novi Sad Faculty of Medicine, Novi Sad, Serbia; 3AdventHealth Transplant Institute, Orlando, FL Objectives: Conundrum health care providers and institutions face is how to deliver evidence-based medical care at lower cost to an ever expanding portion of society in need. Translation of clinical studies to daily practice and adoption of national and international guidelines have not met expectations. This disappointing shortfall stems primarily from lack of interface between ever growing and changing vast medical literature and individual patient profile. Concurrently, threats of penalties for