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CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

  • Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

  • Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
  • Limit personnel on the scene to only those essential for patient care.
  • In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
  • It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

 

  • Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk
Strategies
  • Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
  • After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
  • Minimize the likelihood of failed intubation attempts by doing the following:
    • Assign the provider/approach with the best chance of first-pass success, and
    • Pause chest compressions while intubating with minimal disruption.
  • Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
  • Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
  • Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

  •  Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies
  • Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
  • Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Transcatheter Interventions of the “Forgotten Valve”

We have witnessed tremendous advances in the transcatheter therapies for various cardiac conditions in the past couple of decades! The “forgotten valve” usually refers to the tricuspid valve, due to the fact that most of the research in the literature is on the left-sided heart valves. In the past two decades, although there has been progressive interest in implementing transcatheter techniques to treat tricuspid valve pathologies, we are still in the early stages of this development.  So, I decided to write briefly about some of these transcatheter techniques, which will continue to improve in the future; as we get more experience with these tools and continue to implement the advances in related technologies.

Tricuspid Valve Interventions

There are two main types of transcatheter interventions of the tricuspid valve: repair and replacement.

  • Tricuspid Valve Repair

Tricuspid valve repair can involve the tricuspid annulus and/or leaflet coaptation. Leaflet coaptation is performed using the off-label use of MitraClip (Abbott) in the tricuspid valve (also known as TriClip), mainly because of the device availability and operator familiarity [1]. There are other repair systems to repair the tricuspid leaflet coaptation, including Forma (Figure 1) and Pascal systems from Edwards Lifesciences.  The Forma repair system consists of a spacer that occupies the regurgitant orifice and thus decrease regurgitation. The Pascal repair system consists of two paddles, clasps and a spacer, thus overcoming some of the limitations of Forma repair system regarding anchoring and dislodgement [1]. Other repair interventions involving the annulus are usually performed using sutures or an annuloplasty ring (Figure 2) [1].

Figure 1: Forma repair system (Edwards Lifesciences), which is a transcatheter approach to improve the leaflet coaptation of native tricuspid valve by occupying the regurgitant orifice area [2].

Figure 2: Cardioband (Edwards Lifesciences) is a transcatheter annuloplasty ring for the tricuspid valve [3].

  • Tricuspid Valve Replacement

The first transcatheter tricuspid valve replacement was performed by Kefer et al in 2014 using the balloon-expandable SAPIEN valve (Edwards Lifesciences). There are 6-7 types of dedicated transcatheter tricuspid valves that have been developed in the recent years; these include NaviGate (NaviGate Cardiac Structures, Lake Forest, California), Edwards Evoque, Medtronic Intrepid, Lux (Chinese designed and manufactured self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame), and Tricares (TRiCares GmbH, München, Germany) valve is a self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame. Figure 3 illustrates a NaviGate valve, which is the first tricuspid prosthetic valve implanted in humans in the United States, which was performed by Navia et al in November 2016 [1].  It is an example of a self-expanding dedicated tricuspid valve with 3 pericardial leaflets.

Figure 3: NaviGate valve, which is currently available for transcatheter tricuspid valve replacement [4].

  • Caval Stenting

In addition, stenting of the inferior and/or superior vena cava has also been performed to mitigate the effects of tricuspid regurgitation on the central venous system. It is another option for those patients with tricuspid regurgitation, but there are concerns that this procedure might ultimately promote significant hemodynamic deterioration, with ventricularization of the right atrium and increased load on the right ventricle. Ongoing studies are being conducted to assess these effects and the outcomes of this procedure [1].

Do transcatheter interventions of the tricuspid valve affect mortality?

So far, the current evidence we have is from observational studies suggesting improved mortality in patients treated with tricuspid repair/replacement compared to medical therapy [1]. Overall, these transcatheter interventions have shown significant improvement in patient’s symptoms and New York Heart Association (NYHA) functional class, despite only moderate reduction in tricuspid regurgitation severity [1]. There are multiple ongoing trials assessing the impact of these therapies on outcomes.  The TRILUMINATE trial is one example, which is comparing outcomes of tricuspid clipping to medical treatment in patients with functional tricuspid regurgitation.

In conclusion, there are several transcatheter therapies that have been developed for treatment of tricuspid valvular pathologies, most commonly for functional tricuspid regurgitation, in the past few years. Although most of these techniques are still in their early stages, the initial results of the observational data are promising. I look forward to seeing the advances in these therapies in the near future, as we continue to build our experience as operators and familiarize ourselves with these new advanced tools.

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Innovations in 3-D and 4-D Technology in the Cath Lab

There have been tremendous advances in 3-dimensional (3-D) technologies in the past few years, not only in various medical and surgical fields but also in our daily lives outside of work; with more and more new features in cell phones, computer design programs, and movies!!  4-dimensional (4-D) imaging captures 3-D images over time. These technologies are particularly important in cardiology, especially in interventional cardiology. The heart is a very dynamic organ, and understanding the variation in the anatomy of vessels and geometry of cardiac structures is key to ensuring successful procedures, patient’s safety and good outcomes. More recently, newer innovations in both 3-D and 4-D technologies have been developed, so I decided to shed light on some of these innovations and how they can be potential game-changers in the cath lab.

  • 3-D Holograms

This technology was actually displayed at the Transcatheter Cardiovascular Therapeutics (TCT) 2019 meeting. It converts live transesophageal echo (TEE) imaging into real-time 3-D holographic video in the cath lab to aid structural heart procedures.  The 3-D hologram is projected on a special display screen, and the interventional cardiologist uses hand movements and a foot pedal/switch to change the image orientation without breaking the sterile field. It also allows the operator to see the tools they use in the cath lab, including catheters or devices, in real-time in a 3-D format. This technology does not even require the user to wear 3-D glasses! It was submitted for FDA regulatory review in September 2019.

  • HeartFlow Planner

This is a noninvasive, real-time virtual tool for coronary artery disease intervention. It allows interventional cardiologists to virtually map vessels on a 3-D coronary tree, with color codes indicating the fractional flow reserve-computed tomography (FFR-CT) values for each vessel as measured by a computational fluid dynamics algorithm. This seems to be a good tool for percutaneous coronary intervention (PCI) planning in vessels with significant disease; as it aims to provide us with a non-invasive way to determine whether a stenotic lesion if potentially flow limiting. However, it is important to note the CT-FFR has its own limitations, and some patients might still need invasive FFR for accurate assessment. This tool was approved by the FDA in September 2019.

Figure 1: 3-D CT-FFR coronary tree showing both flow limiting and non-flow limiting lesions [from reference 1].

  • 3-D Printing

3-D printing has been used in the surgical fields for more than a decade. It refers to making complex 3-D objects from computer-aided designs. This technology has been increasingly utilized in structural heart procedures in the past few years, where these 3-D models can be printed from a patient’s CT, magnetic resonance imaging (MRI), or 3-D ultrasound images (Figure 1). These 3-D printed structures not only help with procedural planning and device sizing but also allow operators to practice dry runs and perform pre-procedural navigation.

Figure 2: Image of a 3-D printed model which shows cardiac valves and major vessels with their geometric locations relative to each other (reference 3).

  • 4-D Imaging

4-D imaging adds an important component to 3-D imaging, which is the change of these 3-D images over time. 4-D flow images include the direction of blood flow, blood velocities and shear wall stress [2] (Figure 3). This is particularly important in coronary interventions, structural heart procedures and different congenital abnormalities where identification of blood flow in the 4-D view is useful, especially when the anatomy is complex. These changes in position over time help guide our procedures, not only to ensure successful outcomes but also to avoid potential complications. These 4-D images require large amounts of data, but they can be obtained from either cardiac MRI or computational fluid dynamics, which is a specialized area of mathematics and fluid mechanics in engineering [2]. 4-D imaging is still in its early phases, but it is another exciting advancement in our field.

Figure 3: Representation of an MRI-generated 4-D flow image showing blood flow through the aorta and major vessels (reference 4).

In conclusion, we have seen and continue to see tremendous advances in the innovations of 3-D and 4-D imaging with important implications in our work in the cath lab. With our continued collaboration with informational technology experts, engineers, and scientists, these innovations are potentially game-changers in different fields, including coronary interventions and structural heart procedures. I look forward to seeing how this technology continues to evolve in the coming decades!!

References:

  • Fornell, Dave “Overview of the top news and new technologies at the 2019 Transcatheter Cardiovascular Therapeutics meeting”, November 2019,

https://www.dicardiology.com/article/6-hot-topics-interventional-cardiology-tct-2019

https://www.itnonline.com/content/arterys-showcases-fda-cleared-4d-flow-mri-software-rsna-2016

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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How is the COVID-19 pandemic affecting cardiac patients and the cath lab?

Amongst the uncertainty of the future and how this pandemic will end, there comes a huge responsibility on all healthcare workers to care for the sickest patients while staying safe, to lead their healthcare systems and to come together as one unit against this crisis. Seeing how this pandemic has affected our healthcare system, from the evolving utility of telehealth to canceling elective procedures in multiple specialties, I decided to share a few thoughts on COVID-19 and the cardiovascular manifestations associated with this infection and how COVID-19 has affected our approach to commonly performed procedures in the cardiac catheterization lab.

Cardiovascular manifestations of COVID-19

Although coronavirus predominantly affects the respiratory system, causing a variety of symptoms from flu-like symptoms to acute respiratory failure requiring intubation, it can affect other organs, and patients may present with non-respiratory complaints [1]. The cardiovascular manifestations of COVID-19 have a wide range of clinical presentations (Figure 1), from pericarditis, myocarditis, pericardial effusion, and decompensated heart failure to tamponade, cardiogenic shock and ST-elevation myocardial infarction (STEMI) [1-2]. In addition, right ventricular strain should raise suspicion for pulmonary embolism as these infected patients tend to be hyper-coagulable with a high incidence of venous thromboembolism for currently unclear reasons. It is important to recognize these cardiovascular manifestations of COVID-19, as it is thought that cardiovascular involvement is associated with a worse prognosis [1].

Figure 1: Potential risk factors and cardiovascular manifestations of COVID-19 patients.

Approach to Acute Coronary Syndrome (ACS) and Structural Procedures in the Cath Lab in COVID-19 Pandemic

Like any procedural field, interventional cardiology has been affected by this pandemic. All elective procedures are being postponed until the crisis settles down per recommendations from the Centers for Disease Control and Prevention (CDC), with emergent, urgent, time-sensitive procedures still being performed, in an attempt to preserve hospital beds and personal protective equipment (PPE) for COVID-19 patients [2]. This pandemic has led to several changes in the ACS approach across the world, with the main goal of reducing un-necessary exposure to health care workers and limiting the spread of this highly contagious disease [1,2].

To summarize, some of the key changes many hospitals have applied in their approach to some of the most commonly performed percutaneous cardiac procedures in COVID-19 patients:

  • ACS patients
  • Thrombolytics are considered standard therapy in many hospitals for many STEMI patients with symptoms <12 hours and no contraindications: signs of success are resolution of symptoms and/or >50% decrease in ST elevation. If thrombolytics fail, coronary angiogram and percutaneous coronary intervention (PCI) should be considered in an isolated cath lab (Figure 2) and the benefit versus the exposure risk should be carefully evaluated.
  • For patients with low risk Non-ST elevation myocardial infarction (NSTEMI): medical therapy is reasonable. For those with high risk NSTEMI or failure of medical treatment, coronary angiogram and/or PCI should be performed. These coronary procedures are usually performed in isolated cath labs with only limited staff in the cath lab room, to avoid unnecessary exposure (Figure 2).
  • Structural heart disease patients
  • For patients who are unstable and have severe aortic stenosis (AS), balloon aortic valvuloplasty (BAV) should be performed emergently to stabilize the patient if this is thought to be the cause of the hemodynamic instability. For those who develop significant aortic regurgitation after BAV, transcatheter aortic valve replacement (TAVR) should be performed.
  • Patients with severe symptomatic AS, TAVR is considered a time-sensitive procedure. The benefit of TAVR and risk of infection exposure should be discussed.It is important to note that this change in policy, in part, could explain the decrease in cath lab activation rates for STEMI during this pandemic [2]; as many STEMI patients are receiving thrombolytics. In addition to that, many patients are not seeking medical care, or if they do, they are presenting late, possibly due to fear from contracting the virus in the hospital, potentially leading to late STEMI complications [2]. Thus, it is important to counsel our patients in our virtual clinic visits that if significant symptoms develop, they should seek medical care.

Lastly, I want to thank all of my colleagues and healthcare workers across the nation and across the globe for risking their lives for patients and for their continued dedication. This is a critical time for everyone in the health care system. In light of this pandemic, I hope we continue to learn and share our experiences in this global crisis in order to improve our patient’s care, safety for our healthcare workers and the dynamics of our healthcare system.

Figure 2: Simplified Set-up of an Isolated Cath Lab during the COVID-19 pandemic.

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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The Robotic Technology in Interventional Cardiology

The past few years have witnessed amazing advances in the robotic technology leading to its widespread utilization in both research and clinical aspects across multiple fields, including the cardiovascular field! I have recently attended a few conferences and the footprint of the robotic technology has been remarkable in each of them, emphasizing the great interest in the progress and utility of technology in our field. I decided to talk about robotic technology in interventional cardiology, the advantages and limitations of its use, and how I see it impacting the future of interventional cardiology.

  • How long have we used robotic technology in the cath lab?

Robotic technology has been used in surgical specialties and radiation therapy since the mid-1990s. Then, robotics systems for endovascular interventions were developed and have been utilized for different percutaneous interventions, including simple and complex coronary and peripheral interventions, as well as other structural heart disease procedures, including atrial septal defect closure.

  • Do we have scientific evidence-based trials assessing the robotic technology in interventional cardiology?

There are many prospective trials looking at robotic technology in both coronary and peripheral interventions. The two major studies are:

  1. PRECISE (Percutaneous Robotically Enhanced Coronary Interventions) trial: 164 patients with relatively simple lesions (>87% ACC/AHA type A/B; lesion length 12.2 6 4.8 mm), the investigators reported clinical success of 97.6%, technical success of 98.8% and > 95% median operator radiation reduction. Based on the results of this study, in 2012, the FDA approved the CorPath 200 System as the first robotic system for PCI.
  2. The RAPID (Robotic-Assisted Peripheral Interventions for Peripheral Artery Disease) trial, a prospective single-center, safety and feasibility study demonstrated the utility of the CorPath 200 system for robotic peripheral interventions. The study demonstrated 100% device technical and clinical success. No significant adverse events related to the device were reported, and based on this study, the CorPath 200 system received FDA approval for peripheral interventions.
  • Advantages
  • One of the main advantages of the robotic system in the cath lab is the reduction of radiation exposure for both the operators. The hazards of radiation are well-known and studies have demonstrated that the use of robots led to a reduction in radiation exposure [1]. Operators using the robotic system can either be in the cath lab several feet away from the radiation source or even in a separate room, where they can control the joystick and use the control pad to adjust the robot movements to control wires, the guide catheters and other devices (balloon, stents, etc..).
  • Robots also help avoid wearing heavy lead aprons and thus decrease the orthopedic problems that many operators suffer from in the long run, including back pain and arthritis.
  • Moreover, studies have also shown that robotic system use is associated with good precision and outcomes [1].
  • Robots have been increasingly utilized with around 100 hospitals in the US currently using robots in the cath lab. This quick and widespread utilization of this new technology demonstrates not only how safe and successful the robotic system is, but also how easy and user-friendly it is.

 

  • Limitations

In my opinion, this tool was developed to help operators, but not to replace them. Like any tool, the machine can potentially stop working, for a technical reason or other reasons, and at the end of the day, it is the physician’s responsibility to deal with the situation and solve the problem. In addition, the use of robotic system is limited in the following:

  • The use of robotics in STEMI or bifurcation lesions has not been well-established yet, although reports and smaller studies have shown it can be performed safely.
  • There are technical limitations of the robotic system, and if a lesion could not be treated, manual conversion is recommended.
  • Limited devices used by the current generation of robotic technology: use of over-the-wire balloons, intra-vascular imaging catheter, or mechanical circulatory support is not available with the current generation of robotics.
  • How will robots change the future of interventional cardiology?

The robotic technology has been increasingly utilized in multiple hospitals across the world. With more experience with robotic technology utilization, more knowledge and future upgrade of robotic systems, I think this tool will be increasingly utilized and updated to conform to the needs of patients, operators and different kinds of procedures and interventions; in fact, the robotic system is being studied in the utility of transcatheter aortic valve replacement (TAVR) procedures! Moreover, the utility of the robotic technology could potentially enable experienced operators to remotely perform complex interventional procedures in patients in different hospitals in rural or urban areas, different states, different countries or even different continents!

With the rapid progress in technology in all fields of our life, I think it is very important to establish and encourage more collaborations between technology and medical sciences, especially in procedural specialties, where precision and safety can be provided by these advanced robotics systems for optimal outcomes. I look forward to seeing how these technologies will evolve and transform our practice in the future!!

 

I would like to thank my colleague and friend, Dr. Jeff Hsu, for his help on this blog and for being an awesome senior buddy!!

References

  • Mahmud et al: Robotic technology in interventional cardiology: Current status and future perspectives. Catheter Cardiovasc Interv.2017 Nov 15;90(6):956-962.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.27209

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The American Heart and Go Red for Women Month!

It is February: The American Heart and Go Red for Women Month!

February has just started with all its excitement and optimistic thoughts!! I would like to talk about some of the amazing initiatives, including American Heart Month and Go Red for Women initiatives, that are in place to inspire and encourage more of my colleagues, women and men equally, to step up and be proactive about women’s health and education!

  • When was the first American Heart Month?

It was in February 1964, proclaimed by President Lyndon B. Johnson, and Congress subsequently requested the President to issue a proclamation designating February as American Heart Month annually.

  • What is the Go Red for Women Initiative?

It is an initiative, launched in 2004, to end heart disease and stroke in women; by increasing awareness of these diseases in women and removing barriers women face to achieve a healthy life. Here is what GO RED means:

  • G: GET YOUR NUMBERS

Ask your doctor to check your blood pressure and cholesterol.

  • O: OWN YOUR LIFESTYLE

Stop smoking, lose weight, exercise, and eat healthy.

  • R: REALIZE YOUR RISK

Know your risk; heart disease is responsible for 1 in every 5 female deaths [1].

  • E: EDUCATE YOUR FAMILY

Make healthy food choices for you and your family.

  • D: DON’T BE SILENT

Tell every woman you know that heart disease is our No. 1 killer [1].

  • How about “Research Goes Red” initiative?

It is an initiative to increase women’s participation in scientific research. Both healthy women and those with acute or chronic diseases are encouraged to participate.

  • What impact have these initiatives achieved?

The impact of these initiatives has been remarkable and quite impressive!! Here are some of their achievements:

  • More than 25,000 women registered for the Research Goes Red initiative!
  • Around 19 million women interact with Go Red through digital platforms annually.
  • $600 million raised to support research, education, advocacy, prevention and awareness programs.

Seeing the impact of these initiatives, I am hopeful not only that these initiatives continue to include and support more women, but also I am optimistic that more initiatives are launched to: (1) increase awareness of different heart diseases in women, (2) empower women to know the differences in the clinical presentations of different diseases, (3) implement strategies to avoid health care disparities based on gender and race, and (4) help more women and minorities access health care, not only across the nation but also across the globe.

 

Reference

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock

Mechanical circulatory support (MCS) use in cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is one of the most controversial topics in cardiology. Despite advances in many aspects in our cardiovascular field, mortality from CS remains unacceptably high. At the most recent AHA meeting, two studies suggested the use of intra-aortic balloon pumps (IABP) in CS might result in better outcomes compared to use of the percutaneous MCS device, Impella. I wanted to share my thoughts and ideas on this topic in light on these studies.

Major Randomized Clinical Trials on MCS

There is limited evidence in the literature supporting the use of MCS in AMI-CS1-3. There are two main randomized clinical trials in MCS devices: IABP-SHOCK II and IMPRESS trials. IABP-SHOCK II trial compared IABP with medical treatment in 600 patients with AMI-CS, and showed no difference in survival between the two groups2. The IMPRESS trial compared Impella CP versus IABP in 48 patients with CS-AMI and again did not show a difference in survival between these groups3.

Summary of recently-released studies at AHA19

A study by Amin et al, which included 48,306 patients undergoing percutaneous coronary intervention (PCI) with MCS from the Premier Healthcare Database, found wide variations in the use and clinical outcomes of Impella (mortality, stroke, bleeding, acute kidney injury) across hospitals. They also found that Impella had higher odds of adverse events and higher costs compared to IABP after adjusting for hospital, patients and time period4.

A separate study by Dhruva et al, which included 28,304 matched patients with AMI-CS undergoing PCI from NCDR Cath-PCI registry, found that 8,471 patients (29.9%) had IABP only, and 1,768 patients (6.2%) had Impella only. In-hospital outcomes were compared; in-hospital mortality was 34.1% with IABP compared to 45% with Impella use, and in-hospital bleeding rates were also lower in IABP group with 16% versus 31.3% in the Impella group5.

Discussion

In light of the results of these two observational real-world studies, I think we should take these results with a grain of salt. As we know, observational data has its own limitations, including confounding bias. Patients with AMI-CS may differ significantly based on their co-morbidity profile and angiographic complexity, which could potentially influence device selection; as we expect that patients who are sicker will usually get Impella as it provides more hemodynamic support compared to IABP, making comparison between these two devices inaccurate.

Both studies have shown an increase in the use of Impella over the past years, which is an opportunity to study these devices with larger numbers in different clinical settings. Registries across the nation are being established to build databases to compare these devices. Stronger evidence and more robust data with potential randomized clinical trials are much needed to help us know how to best manage this complex patient population and select which MCS device is optimal for each of our patient populations.

I would like to say special thank you to Dr Khaldia Khaled, my friend and colleague at Louisiana State University, for helping me write this blog and for her continued support.

 

References 

1- Schrage B et al: Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock. Circulation. 2019 Mar 5;139(10):1249-1258.

2- Thiele et al: Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med 2012; 367:1287-1296. DOI: 10.1056/NEJMoa1208410

3- Ouweneel DM et al: Experience from a randomized controlled trial with Impella 2.5 versus IABP in STEMI patients with cardiogenic pre-shock. Lessons learned from the IMPRESS in STEMI trial. Int J Cardiol. 2016 Jan 1;202:894-6. doi: 10.1016/j.ijcard.2015.10.063. Epub 2015 Oct 9.

4- Amin et al: The Evolving Landscape of Impella® Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention with Mechanical Circulatory Support.

Circulation. 2019 Nov 17. doi: 10.1161/CIRCULATIONAHA.119.044007.

5- https://www.tctmd.com/news/more-adverse-events-higher-costs-impella-new-observational-studies

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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My Experience at AHA19 Scientific Sessions

#AHA19 was an amazing meeting in all aspects!! I totally enjoyed every moment and definitely recommend all fellows and early career cardiologists to attend and participate in this important meeting. I will share my experience and highlight important sessions fellows and early career colleagues should not miss.

The fellow-in-training (FIT) and Early Career Lounge

The FIT/Early Career Lounge is always open and welcoming to all fellows. There were amazing sessions throughout the meeting guiding fellows in issues that matter to them at their current level of training or practice. There were great talks by experts in the field for those who were interested in scientific writing, pursuing a career in interventional cardiology, electrophysiology, heart failure, imaging…etc These sessions were packed with fellows and early career colleagues from all over the world. After each session, there were productive discussions between the audience and the speakers, that helped further make it extremely useful sessions to attend.

The Go Red Women in Science and Medicine Lounge

The Go Red Women in Science and Medicine Lounge was also packed by great talks and tips by amazing women leaders in the field. Topics ranged from time/priority management, collaborations between scientists and MDs in clinical practice, and how to advocate for women in our exciting cardiovascular field. Similarly, each session was followed by extremely helpful tips and discussions that is very relevant to all of us, regardless of our level of training or career level.

The AHA Presidential Session

The AHA Presidential session was one of a kind! Dr Robert Harrington shared his inspiring journey how he became involved in AHA and scientific research, emphasizing why evidence matters and how we all can contribute to this amazing cardiovascular field. We were all very excited and delighted by the Hamilton performance as well!!

Late Breaking Trials

Needless to say, the late and non-late breaking trials at #AHA19 were very relevant to our clinical practice, from ISCHEMIA, ISCHEMIA-CKD, GALILEO, COLCOT, RECOVERY, DAPA-HF and many other trials. These results were released in packed halls with standing attendees, showing the importance of these trials to our daily practice.

Technology/Simulation Hall and Poster Sessions

Moreover, there were concurrent sessions throughout the meeting for those of us who like to practice and use their hand skills in the technology and simulation hall, where you get to use the most up-to-date tools and equipment, including wires and simulation devices. In addition, the poster sessions were a great opportunity to engage in basic and clinical science and exchange ideas with researchers across the globe.

In conclusion, AHA19 was a great meeting that combined both basic and clinical sciences with emphasis on one goal: Evidence Matters for Better Patient Care. I look forward to AHA20 in Dallas, Texas on November 14-16!!

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.