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STUDY DESIGN.: We report a case of pulmonary embolism of polymethylmethacrylate material after percutaneous vertebroplasty. OBJECTIVE.: To describe a severe vertebroplasty complication, the pulmonary embolism, which proved to be fatal in a patient with many chronic disabilities. SUMMARY OF BACKGROUND DATA.: Until 2007, the literature noted that the risk of embolism of polymethylmethacrylate after a percutaneous vertebroplasty counted a small number of pulmonary cement embolism and a smaller number of fatal consequences. The most recent research revealed that the risk of a pulmonary cement embolism ranges from 3.5% to 23% for osteoporotic compression fractures. METHODS.: This study is a case report of an 80-year-old patient with multiple medical comorbid factors, chronic obstructive pulmonary disease, mild renal failure, osteoporosis, and hepatic cirrhosis. Symptoms of pulmonary embolism developed 1 month after a percutaneous vertebroplasty. An echocardiography report suggested that the cement infiltrated the right atrium and the right pulmonary artery, and this was confirmed by a computed tomographic scan. As the therapy with oxygen and low-molecular-weight heparin failed to solve the thrombus, the patient required a surgical tricuspid annuloplasty and the extirpation of the right atrial and right pulmonary masses. RESULTS.: The course of the operation was complicated by pulmonary infection, and the patient ultimately succumbed to infection/respiratory failure. CONCLUSION.: The presence of intravascular/intracardiac foreign bodies is underreported in literature, but it is quite common in clinical practice. We need to discuss the choice of some non-risk-free interventions such as vertebroplasty in older patients already affected by multiple main disabilities. [ABSTRACT FROM AUTHOR]

Neurohormonal blockade (NHB) is the cornerstone of medical therapy for heart failure (HF) with reduced left ventricular ejection fraction. Whether NHB improves HF outcomes among advanced HF patients receiving mechanical unloading with a durable left ventricular assist device (LVAD) remains poorly characterized. Out of 175 consecutive patients undergoing continuous-flow LVAD implant between 2010 and 2020 at our Institution and alive at 6 months on support, 165 (94.3%) had available data on medical therapy comprising the study population. Medical therapy at 6-month visit along with clinical reasons for NHB non-prescription or non-uptitration were retrospectively assessed. The primary outcome was a composite of first HF hospitalization or cardiovascular death occurring from the 6-month assessment up to 5 years from LVAD implant. Multivariate Cox regression models were adjusted for demographics, year of LVAD implant and in-study outcome predictors (concomitant cardiac surgery during LVAD implant, early INTERMACS right ventricular failure, 6-month heart rate and major bleeding). After the 6-month visit, 76% of the patients were on renin-angiotensin-aldosterone system inhibitor (RAASi), 89% on beta-blocker and 75% on mineralocorticoid receptor antagonist (MRA). Patients characteristics among those receiving and not receiving NHB agents at 6-month visit were mostly similar and clinical reasons for NHB non-prescription or non-uptitration could not be found in the majority of cases. RAASi (adj-HR 0.23, 95%CI 0.09-0.58) and beta-blocker (adj-HR 0.24, 95%CI 0.07-0.82) were independently associated with the primary outcome, while MRA was not (adj-HR 1.51, 95%CI 0.57-4.05). Patients on dual/triple NHB had reduced odds of the primary outcome (vs. no/single NHB: adj-HR 0.21, 95%CI 0.07-0.63), while no dose-effect relation was observed for neither RAASi nor beta-blocker. Among advanced HF patients on LVAD support, NHB is associated with improved HF outcomes. Our findings suggest the importance to start or continue NHB agents early after LVAD implant and to prioritize combination of NHB agents over the achievement of a single-agent target dose as the primary treatment goal. [ABSTRACT FROM AUTHOR]

Optimal invasive hemodynamics are associated with improved long-term outcomes among patients on durable left ventricular assist device (LVAD) support. Less is known about the optimal echocardiographic profile. We assessed the independent association of parameters from a comprehensive echocardiography exam acquired at 6-month post-LAVD implant with the primary endpoint of hospitalization for heart failure or cardiovascular death at last follow-up (2.4 years, 1.3-4.4 years). 175 consecutive patients undergoing LVAD implant at our Institution between 2010 and 2020 and alive at 6 months on support were the study population. Echocardiography was available for all patients. Primary endpoint rate was 21.7%. Left ventricular end-diastolic dimension, continuous aortic valve opening, grading of mitral, tricuspid and aortic regurgitations, right ventricle basal diameter and dysfunction grading, and estimated right atrial pressure (eRAP) ≥15 mmHg were associated with the primary outcome. At multivariate analysis, mitral regurgitation grade and elevated eRAP remained independent outcome predictors. The currently recommended definition of optimal echocardiographic profile on LVAD support (mitral regurgitation <2+/4+ and neutral septal position) was not independently associated with the outcome, while being so when eRAP<15 mmHg was integrated (adj-HR 0.27, 95%CI 0.09-0.79). In an exploratory analysis, the new definition was associated with all-cause mortality (adj-HR 0.39, 95%CI 0.18-0.82). A new outcome-driven definition for the on-LVAD optimal echocardiographic profile is proposed. Elevated eRAP in stable LVAD patients is an ominous prognostic marker, potentially actionable through LVAD speed optimization and medical therapy. [ABSTRACT FROM AUTHOR]