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Goals:The goal of this study was to evaluate the influence of defecation postural modification devices (DPMDs) on normal bowel patterns.Background:The introduction of DPMDs has brought increased awareness to bowel habits in western populations.Materials and Methods:A prospective crossover study of v

Introduction: Atrial fibrillation (AF) is known to occur after blood and/or marrow transplant (BMT) and has been shown to increase morbidity and mortality. Our objective was to characterize the incidence, risk factors, and clinical impact of AF in patients within the first 90 days after BMT. Methods: Patients with active malignancy undergoing BMT from 2012-2016 at the Medical College of Wisconsin were included (n=1159). Medical records were reviewed for baseline patient characteristics, AF risk factors, and clinical outcomes. Patients were categorized based on development of AF within 90 days post-BMT. Baseline characteristics and risk factors were analyzed to determine predictors for AF and all-cause mortality at 90 days. Results: Amongst the entire cohort, 5.3% of patients developed AF within the first 90 days after BMT. Significant baseline differences between those with or without AF post-BMT are outlined in Table 1. Multivariable analysis showed that a history of AF (OR: 6.7; 95% CI: 3.3-13.6; P = P = 0.018) were independent predictors of developing AF. Univariate analysis demonstrated that AF was associated with 90-day mortality (HR: 7.6; 95% CI: 3.5-16.5; log rank P < 0.001). Multivariable analysis (adjusted for age, gender, race, history of XRT, BMT type, and malignancy type) revealed that female gender (HR: 2.6; 95% CI: 1.2-5.5; P = 0.016), non-Caucasian race (HR: 2.7; 95% CI: 1.1-6.4; P = 0.024) and development of AF (HR: 9.2; 95% CI: 3.7-21.5; P < 0.001) were significant independent predictors of early mortality. Conclusions: This analysis demonstrated that a prior history of AF and prior XRT were independent predictors for the development of AF in the early period post-BMT and AF is a significant independent predictor of early mortality after BMT. Further studies assessing the potential benefits of AF prevention in patients after BMT is warranted.

Background Antineoplastic therapy with the tyrosine kinase inhibitor pazopanib in patients with advanced/metastatic renal cell carcinoma (mRCC) has been associated with hypertension (HTN), cardiomyopathy, and cardiac dysrhythmias. We therefore assessed the cardiovascular (CV) risk with pazopanib in a clinical setting. Methods Medical records of 35 antineoplastic-naïve mRCC patients newly started on pazopanib were retrospectively reviewed at a single academic medical center. Assessment of the hypertensive response and adverse cardiac events associated with pazopanib was the primary objective. Outcomes were defined using the National Cancer Institute’s Common Terminology Criteria for Adverse Events v4.0. Potential clinical risk factors were investigated with univariate and multivariable logistic regression. Results Pazopanib-induced HTN was observed in 57% of patients. Median maximal systolic blood pressure (SBP) during pazopanib treatment was 167.5 mmHg with median time to event of 24.5 days. New-onset HTN occurred in 6/14 (43%) patients. Baseline SBP > 130 mmHg (odds ratio [OR]: 5.32; 95% confidence interval [CI]: 0.94-29.99; p = 0.058) and ACEi/ARB use (OR: 4.88; 95% CI: 1.05 22.84; p = 0.044) were risk factors for pazopanib-induced HTN. When HTN was excluded, 34% of patients developed a CV adverse event. Age ≥ 60 years (OR: 8.72; 95% CI: 0.74-513.26; p = 0.105) trended towards being a predictor for a non-HTN CV adverse event. Conclusions Our findings suggest that pazopanib has a broad CV toxicity profile in treatment-naïve mRCC patients headlined by a rapid and striking hypertensive response. More intensive BP control prior to starting pazopanib and standardization of CV surveillance particularly in older patients may optimize oncologic care while minimizing CV risk.

BACKGROUND An internal risk stratification algorithm was developed to decrease the risk of major adverse cardiac events (MACEs) during lead extractions (LEs). OBJECTIVE To report upon the impact of a risk stratification algorithm (RISE [RIsk Stratification prior to lead Extraction] protocol) on outcomes of LEs in a high-volume center. METHODS A retrospective review of a prospectively maintained LEs database was performed to identify features associated with MACEs. On the basis of the retrospective data, the RISE protocol differentiated LEs procedures into "High" and "Low" risk for occurrence of MACEs. High-risk LEs included dual-coil defibrillator lead (≥3 years), pacemaker and single-coil lead (≥5 years), and any StarFix coronary sinus lead. During the prospective evaluation of the RISE protocol, "High-risk" LEs were performed in an operating room (OR) or hybrid laboratory with the cardiac anesthesiologist, OR nursing team, perfusionist in the room, and a cardiac surgeon on the premises. "Low-risk" LEs were performed in the electrophysiology (EP) laboratory with anesthesia provided by EP nursing team. The preintervention (pre-RISE) and postintervention (post-RISE) group spanned 19 and 40 months and consisted of 449 (632 leads) and 751 patients (1055 leads), respectively. The primary outcome of MACEs in the two groups was compared. RESULTS Protocol compliance was 100%. The primary outcome of MACEs occurred in 15 patients (3.34%) before and 12 (1.6%) after implementation of the RISE protocol (P = .04). CONCLUSION RISE identified a low-risk group where minimal resources are needed and allowed for rapid intervention in the high-risk group that reduced the consequences of MACEs.

Background Venous congestion in heart failure (HF) may lead to worsening renal failure (WRF). We hypothesised that WRF in patients hospitalised for left ventricular assist device (LVAD) implantation is associated with increased 1-year mortality. There is limited data regarding WRF in HF patients with mechanical support. The objective of this paper is to determine whether WRF in HF patients hospitalised for LVAD implantation is associated with increased 1-year mortality and to identify risk factors for WRF. Methods We performed a single centre retrospective chart analysis of 162 patients who received an LVAD between August 2006 and December 2014 with pre-LVAD right heart catheterisation data. We stratified patients to those who demonstrated WRF and the use of haemodialysis (HD) or ultrafiltration (UF). Results Patients with a higher central venous pressure (CVP) >16 mmHg (17–24 mmHg range) developed WRF (29.7% vs. 14.1%, p=0.019). A CVP ≥16 and glomerular filtration rate (GFR) 16 increased the odds of requiring HD/UF. Conclusions Worsening renal failure is associated with a higher CVP at the time of LVAD implantation and increases the risk of 1-year mortality and the odds of requiring HD/UF. Careful evaluation of renal function and comorbid conditions during LVAD implantation is critical to reduce mortality and for risk stratification.

Background Lead dislodgement (LD) is a well-recognized complication during implantation of cardiac implantable electronic devices (CIEDs). An intraprocedural protocol, referred to as reduction of LD protocol, was developed to reduce the risk of LD. Methods The protocol involved (1) inserting a straight stylet down the right atrial lead and applying forward pressure while monitoring for fluoroscopic stability, (2) visualizing all leads during deep inspiration to determine if there is adequate lead redundancy, and (3) having the patient take a deep breath and cough while pacing just at capture threshold to assess for loss of capture in each lead. Any intraprocedural change in the parameters fulfilling the predefined criteria for inadequate lead implantation prompted lead repositioning. Data regarding demographic factors, clinical characteristics, and incidence of LD in the first 30 days after implant was obtained from intramural CIED database. The preintervention (control) group spanned 27 months and consisted of a total of 4,294 leads while the postintervention (intervention) group spanned 17 months and consisted of 2,361 leads implanted. Results There was no significant difference in the demographic factors and clinical characteristics in the two groups. Protocol compliance was > 90%. There were 44 occurrences of LD (1.02%) before and 10 (0.4%) after implementation of the protocol. The protocol significantly reduced the incidence of LD during the 30 days after implant (P = 0.014). No clinical characteristic predicted the risk of LD. Conclusion Intraprocedural maneuvers performed to assess the adequacy of lead implantation results in reduced risk of LD.

Introduction The pulmonary artery pulsatility index (PAPi) is an emerging hemodynamic marker correlated with severe post-LVAD RVF in single-center cohort studies. We set out to examine if this is generalizable in a multi-institutional analysis. Hypothesis The preoperative PAPi correlates with RVF as defined by new INTERMACS criteria (INTERMACS-RVF), severe RVF, and death at 1-year. Methods We performed a dual-center retrospective study of 404 patients from Ohio and New York who received a continuous-flow durable LVAD and had a pre-operative PAPi measurement. The PAPi was defined as: [(PA systolic - PA diastolic) ÷ RA pressure]. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started 14 days after implant, RVAD placement during implant admission, and death from RVF during implant admission. A multivariate analysis of predictors of post-LVAD severe RVF was conducted. A survival analysis was performed to examine pre-operative PAPi as a predictor of 1-year mortality. Results In our cohort of 404 patients, 84 (21%) had severe RVF. Multivariable logistic regression for severe RVF (controlling for age, INTERMACS level, creatinine, and gender) showed that creatinine > 1.5 (OR 2.24, p=0.002, 95% CI [1.43-4.42]) and total bilirubin > 2.5 (OR 2.87, p=0.004, 95% CI [1.39-5.93]) significantly increased the odds of severe RVF, and a PAPi Figure 1 ) and INTERMACS-RVF (c-statistic=0.63) were similar. With respect to survival, the final multivariable model (controlling for age, gender, and ethnicity) showed a PAPi Conclusion PAPi

Introduction Early RVF after LVAD implant has been studied using varying definitions. We set out to compare the new INTERMACS post-LVAD RVF criteria and traditional severe RVF definitions in our multi-institutional cohort. Hypothesis The INTERMACS RVF and severe RVF definition will both show increased mortality at 1-year. Methods We performed a dual-center retrospective study of 471 patients who received a continuous-flow durable LVAD and data available to assess RVF severity. The new INTERMACS RVF definition stratifies RVF into mild, moderate, severe, and acute-severe. Severe RVF was defined as meeting criteria for clinical RVF and having inotropes > 14 days after implant, inotropes re-started after 14 days of implant, RVAD placement during implant admission, and death from RVF during implant admission. A survival analysis of the INTERMACS RVF and severe RVF definitions was performed. A multivariate analysis using clinical markers associated with post-LVAD mortality was then completed to assess the independent effect of the RVF definitions. Results Of the 471 patients, 100 (21%) had severe RVF. Stratified by INTERMACS-RVF, 279 (59%) had no RVF, 37 (8%) had mild RVF, 53 (11%) had moderate RVF, 57 (12%) had severe RVF, and 47 (17%) had acute-severe RVF. Our multivariate model (adjusted for age, gender, and ethnicity) for predictors of 1-year mortality showed that PAPi Conclusion Our multi-institutional cohort shows that severe RVF and INTERMACS RVF severe and acute-severe predict mortality at 1-year, and notably shows that mild and moderate INTERMACS RVF do not predict mortality. The new INTERMACS classification of RVF provides more granularity in stratifying RVF and may be more clinically applicable.

Cardiac extramedullary plasmacytomas (EMPs) are rare and may be a seen as a complication of multiple myeloma (MM) or in isolation. Here, we describe a case of cardiac EMP that presented clinically as a congestive heart failure exacerbation in a patient with relapsed and refractory IgG lambda MM. We highlight radiographic imaging in conjunction with laboratory biomarkers at presentation and in response to D-PACE (dexamethasone, cisplatin (Platinol), doxorubicin (Adriamycin), cyclophosphamide and etoposide) systemic chemotherapy.