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Aim: Our study aims to provide a more holistic understanding of the available data and predictive risk factors for gastrointestinal bleed (GIB). Materials & methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science Core Collection and calculated relative risk and meta-regression was utilized to evaluate for risk factors in order to assess the effect of covariates. Results: Our meta-analysis reported a pooled prevalence rate of GIB of 24.4%. Meta-regression analysis did not yield a statistically significant association between GIB and risk factors, including age, gender, hypertension, chronic kidney disease and diabetes. Conclusion: Studies investigating larger sample sizes are required for conclusive findings.

Epinephrine (EPI), an endogenous catecholamine involved in the body’s fight-or-flight responses to stress, activates α1-adrenergic receptors (α1ARs) expressed on various organs to evoke a wide range of physiological functions, including vasoconstriction. In the smooth muscle of human bronchi, however, the functional role of EPI on α1ARs remains controversial. Classically, evidence suggests that EPI promotes bronchodilation by stimulating β2-adrenergic receptors (β2ARs). Conventionally, the selective β2AR agonism of EPI was thought to be, in part, due to a predominance of β2ARs and/or a sparse, or lack of α1AR activity in human airway smooth muscle (HASM) cells. Surprisingly, we find that HASM cells express a high abundance of ADRA1B (the α1AR subtype B) and identify a spontaneous “switch-like” activation of α1ARs that evokes intracellular calcium, myosin light chain phosphorylation, and HASM cell shortening. The switch-like responses, and related EPI-induced biochemical and mechanical signals, emerged upon pharmacological inhibition of β2ARs and/or under experimental conditions that induce β2AR tachyphylaxis. EPI-induced procontractile effects were abrogated by an α1AR antagonist, doxazosin mesylate (DM). These data collectively uncover a previously unrecognized feed-forward mechanism driving bronchospasm via two distinct classes of G protein-coupled receptors (GPCRs) and provide a basis for reexamining α1AR inhibition for the management of stress/exercise-induced asthma and/or β2-agonist insensitivity in patients with difficult-to-control, disease subtypes.

BACKGROUND This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are limited by cost and availability. METHODS We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD), comparing sarcoidosis group with healthy controls. A random-effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. RESULTS Nine studies were included in our final analysis with an aggregate of 967 patients. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared with controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, P

Warfarin is standard anticoagulation therapy for patients with a continuous-flow left ventricular assist device (CF-LVAD). However, warfarin requires regular monitoring and dosage adjustments and fails for many patients, causing thromboembolic and bleeding events. Factor Xa inhibitors have been shown to be noninferior to warfarin in preventing strokes and are associated with less intracranial hemorrhage in patients with atrial fibrillation. We evaluated treatment safety and effectiveness in CF-LVAD patients who switched from warfarin to a factor Xa inhibitor (apixaban or rivaroxaban) after warfarin failure. This was a retrospective, single-center study of patients treated between 2008 and 2018. We assessed the occurrence of stroke, non-central nervous system (CNS) embolism, pump thrombosis, and major gastrointestinal bleeding and intracranial hemorrhage during therapy. We identified seven patients: five were male, the average body mass index was 30 kg/m2, and average age was 56 years. Preimplantation comorbidities included hypertension (all patients) and diabetes mellitus, ischemic cardiomyopathy, atrial fibrillation, and previous myocardial infarction (four patients each). Overall, patients received warfarin for 3968 days and apixaban/rivaroxaban for 1459 days. The warfarin group was within the therapeutic INR range (2.0–3.0) 30% of the time. Complication rates did not differ between warfarin and apixaban/rivaroxaban: strokes, 0.20 vs none, non-CNS embolism, 0.54 vs none; pump thrombosis, 0.27 vs none; major gastrointestinal bleeding, 0.20 vs 0.50; intracranial hemorrhage, 0.13 vs none. Factor Xa inhibitors may be viable treatment options for CF-LVAD patients for whom warfarin therapy has failed. Large prospective studies are necessary to confirm these results.

Introduction: Real-world data on the significance of adding a defibrillator to cardiac resynchronization therapy (CRT-D) in patients with nonischemic cardiomyopathy (NICM) are limited. Hypothesis: CRT-D is associated with a lower risk of mortality and heart failure (HF) readmissions compared to CRT-P in NICM. Methods: We identified patients with NICM who underwent CRT-D and CRT without an ICD (CRT-P) by analyzing the nationwide readmission database from October 2015- December 2018 and using appropriate ICD-10 CM codes. Propensity score matching was performed to adjust for the confounders. Kaplan Meier curves were utilized for time to event analysis. Cox proportional hazard regression was used to generate hazard ratios. All-cause mortality at 6 months was the primary outcome whereas readmission due to HF and any other cause at 6 months were defined as secondary outcomes. Results: Post-PSM, 3054 patients with NICM underwent CRT-P, and 2863 patients underwent CRT-D placement. CRT-D did not show any benefit over CRT-P in reducing all-cause mortality at 6 months (2.92% vs. 2.79%, HR: 0.84, 95% CI: 0.61-1.16, p=0.29). Similarly, there was no difference in terms of readmissions due to other causes among both groups of patients (36.25% vs. 31.85%, HR: 0.98, 95% CI: 0.89-1.08, p=0.77). However, patients with CRT-P implantations had a lower risk of HF readmissions compared to the CRT-D group (10.05% vs. 14.25%, HR: 0.67, 95% CI: 0.58-0.79, p Conclusions: The addition of a defibrillator to CRT failed to show a survival benefit in patients with NICM. Moreover, HF readmissions were higher in CRT-D patients compared to CRT-P.

Heart failure represents a major growing health problem in developed world. This article aims to review recent heart failure trials that have significantly impacted the management of heart failure.Despite advances in heart failure, mortality and morbidity remains elevated amongst patients. Recent clinical trials demonstrate promising treatment strategies that likely impact clinical practice; including heart failure prevention with the use of SGLT2-inhibitors in patients with diabetes and cardiovascular risk, new treatments that may abrogate disease progression in cardiac amyloidosis, intravenous iron therapy in iron deficiency anemia in chronic systolic heart failure, predischarge treatment with angiotensin receptor blocker with neprilysin inhibition (ARNi) in patients hospitalized for acute decompensated heart failure, and newer continuous flow left ventricular assist device with increased durability and efficacy in patients with Stage D heart failure.Recent clinical trials with SGLT2 inhibitors, therapies targeting transthyretin cardiac amyloidosis, iron, angiotensin receptor blocker with neprilysin inhibition and newer mechanical circulatory support devices are very promising as practice changing new treatment strategies in prevention and treatment of heart failure. This article presents a summary of important trials and should be of practical value to both clinicians and researchers.

Recurrent gastrointestinal bleeding (GIB) is a common complication following left ventricular assist device (LVAD) implantation. Our study aimed to estimate the comparative efficacy of different pharmacologic interventions for the prevention of GIB, through a network meta-analysis (NMA). A total of 13 observational studies comparing six strategies. Among those, 4 were for primary, and 9 were for secondary prevention of GIB. On NMA, thalidomide (Hazard ratio [HR]: 0.016, Credible interval [CrI]I: 0.00053-0.12), omega-3-fatty acid (HR:0.088, CrI: 0.026-0.77), octreotide (HR: 0.17, CrI: 0.0589-0.41) and danazol (HR:0.17, CrI: 0.059-0.41) reduced the risk of GIB. The use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker (ACEi/ARB) and digoxin were not associated with any significant reduction. Based on NMA, combining indirect treatment comparisons, thalidomide, danazol, and octreotide treatments were associated with decreased risk of recurrent GIB. Additionally, Omega 3 fatty acids were associated with a lower risk of the primary episode of GIB in the LVAD patient population.

Background Cardiac sarcoidosis (CS) and arrhythmogenic right ventricular cardiomyopathy (ARVC) are rare causes of ventricular arrhythmias and are associated with sudden cardiac death. Differentiation between both is important for proper management. Case summary We present a 56-year-old man with sudden cardiac arrest and was diagnosed to have ARVC based on cardiac magnetic resonance imaging (MRI). He developed gradually worsening shortness of breath over the next 1 year. CS was unmasked after a cardiac positron emission tomography (PET). Patient was treated with methotrexate. A repeat cardiac PET scan showed improvement. Discussion The distinction between ARVC and CS is challenging. Both these entities have a patchy involvement and can have similar presentations. ARVC has a predominant right heart involvement. It is diagnosed with the help of an MRI, which shows regional right ventricular wall motion abnormality. These findings can have an overlap with CS. It is important to note that, even though sarcoidosis is a pathologic diagnosis, cardiac biopsy is rarely done owing to its patchy involvement. Cardiac PET scan has a high sensitivity and specificity to diagnose this entity. Once diagnosis is made, patients should be treated with immunosuppressants and should be closely followed. Repeat imaging should be considered at intervals to monitor disease progression. This case highlights the importance of multimodality imaging and tissue diagnosis to unmask the diagnosis of CS, a treatable infiltrative disorder which shares features with a potentially untreatable ARVC.

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome, which accounts for about 50% of patients with heart failure (HF). The morbidity and mortality associated with HFpEF is similar to HFrEF. Clinical trials to date have failed to show a benefit of medical therapy for HFpEF, which may due to lack of uniform phenotypes and heterogeneous population. In addition, medical therapy proven for HFrEF may not address the pathophysiologic basis for HFpEF. Left atrial remodeling and dysfunction is central to HFpEF and accounts for secondary pulmonary hypertension and pulmonary vascular congestion that frequently occurs with exertion. Interatrial shunts represent a novel treatment modality for HFpEF. These shunts allow for left atrial decongestion and a reduction in pulmonary venous hypertension during exercise leading to improvements in hemodynamics, functional status and quality of life. Trials to date have demonstrated safety and short-term efficacy of these devices for HFpEF. The long-term benefits are currently being evaluated in ongoing trials. If effective, the use of interatrial shunts may be a new therapeutic paradigm for the treatment of HFpEF.

Background Outcomes of patients with implanted left ventricular assist device (LVAD) implantation experiencing a cardiac arrest (CA) are not well reported. We aimed at defining the in-hospital outcomes of patients with implanted LVAD experiencing a CA. Methods The national inpatient sample (NIS) was queried using ICD9/ICD10 codes for patients older than 18 years with implanted LVAD and CA between 2010–2018. We excluded patients with orthotropic heart transplantation, biventricular assist device (BiVAD) implantation and do not resuscitate (DNR) status. Results A total of 93,153 hospitalisations between 2010 and 2018 with implanted LVAD were identified. Only 578 of these hospitalisations had experienced CA and of those, 173 (33%) hospitalisations underwent cardiopulmonary resuscitation (CPR). The mean age of hospitalisations that experienced a CA was 60.61±14.85 for non-survivors and 56.23±17.33 for survivors (p=0.14). The in-hospital mortality was 60.8 % in hospitalisations with CA and 74.33% in hospitalisations in whom CPR was performed. In an analysis comparing survivors with non-survivors, non-survivors had more diabetes mellitus (DM) (p=0.01), and ischaemic heart disease (IHD) (p=0.04). Age, female sex, peripheral vascular disease and history of coronary artery bypass graft (CABG) were independently associated with increased mortality in our cohort. Also, ventricular tachycardia (VT) and CPR were independently associated with in-hospital mortality. During the study period, there was a significantly decreasing trend in performing CPR in LVAD hospitalisations with CA. Conclusion In conclusion, age, female sex, peripheral vascular disease, history of CABG, VT and CPR were independently associated with in-hospital mortality in LVAD hospitalisations who experienced CA.

Glucocorticoids (GCs) and β2-adrenergic receptor (β2AR) agonists improve asthma outcomes in most patients. GCs also modulate gene expression in human airway smooth muscle (HASM), thereby attenuating airway inflammation and airway hyperresponsiveness that define asthma. Our previous studies showed that the pro-fibrotic cytokine, transforming growth factor- β1 (TGF-β1) increases phosphodiesterase 4D (PDE4D) expression that attenuates agonist-induced levels of intracellular cAMP. Decreased cAMP levels then diminishes β2 agonist-induced airway relaxation. In the current study, we investigated whether glucocorticoids reverse TGF-β1-effects on β2-agonist-induced bronchodilation and modulate pde4d gene expression in HASM. Dexamethasone (DEX) reversed TGF-β1 effects on cAMP levels induced by isoproterenol (ISO). TGF-β1 also attenuated G protein-dependent responses to cholera toxin (CTX), a Gαs stimulator downstream from the β2AR receptor. Previously, we demonstrated that TGF-β1 treatment increased β2AR phosphorylation to induce hyporesponsiveness to a β2 agonist. Our current data shows that expression of grk2/3, kinases associated with attenuation of β2AR function, are not altered with TGF-β1 stimulation. Interestingly, DEX also attenuated TGF-β1-induced pde4d gene expression. These data suggest that steroids may be an effective therapy for treatment of asthma patients whose disease is primarily driven by elevated TGF-β1 levels.

Rationale: Th2 and Th17 cells contribute to airway remodeling, facilitate mucus secretion and increase airway hyperresponsiveness. CD6, a T cell co-stimulatory receptor, interacts with CD166 (ALCAM) and CD318 to modulate activation. We examined whether severe asthma subjects have increased CD6+ cells, the lung inflammatory environment alters CD166 or CD318 expression, and CD6 exposure of airway smooth muscle (ASM) modulates bronchomotor tone. Methods: Lungs (asthma, non-asthma, n=4/group) were lavaged and lymphocytes examined for CD6 by flow cytometry. Tissue was stained for CD166, CD318, CD3, and CD6. ASM stimulated with carbachol (Cch) or CD6-beads was examined for phosphorylation of myosin light chain (pMLC), paxillin (pPax), or cofilin (pCof). ASM were co-cultured with T cells ± IL-33 with CD166 and CD318 expression assessed. Results: Flow analysis showed no difference in CD6+ lavage cells from asthma vs. non-asthma donors. Tissue sections had large differences in lymphocyte number and CD3+/CD6+ cells, with CD166 and CD318 expression on ciliated and basal cells. ALCAM, but not cd318, expression increased in asthma ASM. CD6-coated beads increased pCof and pPax, but not pMLC, to similar levels to Cch. ASM co-cultured with differentiated Th1 cells showed decreased CD166, but not CD318 expression. Co-stimulation with Th1 cells + IL-33 markedly decreased ASM CD166 and CD318 expression. Conclusions: We demonstrate that CD6+ lymphocytes are significantly increased in fatal asthma lung tissue. Furthermore, CD6+ lymphocytes may modulate bronchomotor tone through actin cytoskeletal rearrangements in HASM, and that the inflammatory environment may influence CD6-dependent changes in bronchomotor tone.

Background: Right ventricular failure (RVF) following Left Ventricular Assist Device (LVAD) implantation is associated with worse outcomes. Prediction and early identification of RVF with speckle-tracking echocardiography (STE) has been proposed. Methods: We queried multiple databases for articles reporting on pre-operative/intraoperative global longitudinal strain (GLS) and free-wall strain (FWS) in LVAD recipients. We performed a systematic review and meta-analysis of published literature. The standard mean difference (SMD) in GLS and FWS in patients with and without RVF postoperatively was pooled using random effects model. Results: Fifteen studies, with a total of 967 LVAD recipients were included. There was statistically significant difference in GLS among patients who did and did not develop RVF; SMD= -3.09 (95% CI: -4.62 to -1.57; p-value

Additional file 1: Table S1. Donor demographics for cAMP and pde4d expression studies. All cells were derived from subjects with no history of chronic disease.

Multimedia Internet of Things (MIoT) is uniquely addressable broad network of interconnected objects, it covers many types of different fields of utilization. There are several heterogeneous requirements related applications exists for the same purpose. The MIoT revolution is reforming modern healthcare system with promising technological, economic and social prospects. The extensive distribution of MIoT devices has made the evaluation for performance of MIoT applications very important aspect as relevant placements are present in every daily life activity. Managing the quality of MIoT applications would be natural consequence of the trends. However, evaluating the quality of MIoT applications is substantially diverse from calculating the quality of software systems. This paper attempts to review and understand the quality evaluation parameter to evaluate the overall quality of a MIoT application and challenges in developing good quality evaluation model.

The nongenomic mechanisms by which glucocorticoids modulate β2 agonist-induced-bronchodilation remain elusive. Our studies aimed to elucidate mechanisms mediating the beneficial effects of glucocorticoids on agonist-induced bronchodilation. Utilizing human precision-cut lung slices (hPCLS), we measured bronchodilation to formoterol, prostaglandin E2 (PGE2), cholera toxin (CTX), or forskolin in the presence and absence of budesonide. Using cultured human airway smooth muscle (HASM), intracellular cAMP was measured in live cells following exposure to formoterol, PGE2, or forskolin in the presence or absence of budesonide. We showed that simultaneous budesonide administration amplified formoterol-induced bronchodilation and attenuated agonist-induced phosphorylation of myosin light chain, a necessary signaling event mediating force generation. In parallel studies, cAMP levels were augmented by simultaneous exposure of HASM cells to formoterol and budesonide. Budesonide, fluticasone, and prednisone alone rapidly increased cAMP levels, but steroids alone had little effect on bronchodilation in hPCLS. Bronchodilation induced by PGE2, CTX, or forskolin was also augmented by simultaneous exposure to budesonide in hPCLS. Furthermore, HASM cells expressed membrane-bound glucocorticoid receptors that failed to translocate with glucocorticoid stimulation and that potentially mediated the rapid effects of steroids on β2 agonist-induced bronchodilation. Knockdown of glucocorticoid receptor-α had little effect on budesonide-induced and steroid-dependent augmentation of formoterol-induced cAMP generation in HASM. Collectively, these studies suggest that glucocorticoids amplify cAMP-dependent bronchodilation by directly increasing cAMP levels. These studies identify a molecular mechanism by which the combination of glucocorticoids and β2 agonists may augment bronchodilation in diseases such as asthma or chronic obstructive pulmonary disease.

Pulmonary arterial hypertension (PAH) is a condition associated with substantial morbidity and mortality. Over the last 25 years there has been a significant evolution in the therapies to treat PAH. These therapies are effective for patients with group I PAH and group IV PH [chronic thromboembolic pulmonary hypertension (CTEPH)]. PAH is characterized by an imbalance of nitric oxide, prostacyclin and endothelin levels, and current pharmacotherapy involves these three pathways. Earlier clinical trials involving PAH-specific therapies evaluated improvements in 6-minute walk time as a primary improvement whereas contemporary trials have been larger and focused on morbidity and mortality reductions. While there may be a role for monotherapy in disease management, most patients should be considered for dual or triple therapy.

Rhinovirus (RV) exposure evokes exacerbations of asthma that markedly impact morbidity and mortality worldwide. The mechanisms by which RV induces airway hyperresponsiveness (AHR) or by which specific RV serotypes differentially evoke AHR remain unknown. We posit that RV infection evokes AHR and inflammatory mediator release, which correlate with degrees of RV infection. Furthermore, we posit that rhinovirus C-induced AHR requires paracrine or autocrine mediator release from epithelium that modulates agonist-induced calcium mobilization in human airway smooth muscle. In these studies, we used an ex vivo model to measure bronchoconstriction and mediator release from infected airways in human precision cut lung slices to understand how RV exposure alters airway constriction. We found that rhinovirus C15 (RV-C15) infection augmented carbachol-induced airway narrowing and significantly increased release of IP-10 (IFN-γ-induced protein 10) and MIP-1β (macrophage inflammatory protein-1β) but not IL-6. RV-C15 infection of human airway epithelial cells augmented agonist-induced intracellular calcium flux and phosphorylation of myosin light chain in co-cultured human airway smooth muscle to carbachol, but not after histamine stimulation. Our data suggest that RV-C15-induced structural cell inflammatory responses are associated with viral load but that inflammatory responses and alterations in agonist-mediated constriction of human small airways are uncoupled from viral load of the tissue.

Helper T effector cytokines implicated in asthma modulate the contractility of human airway smooth muscle (HASM) cells. We have reported recently that a profibrotic cytokine, transforming growth factor (TGF)-β1, induces HASM cell shortening and airway hyperresponsiveness. Here, we assessed whether TGF-β1 affects the ability of HASM cells to relax in response to β(2)-agonists, a mainstay treatment for airway hyperresponsiveness in asthma. Overnight TGF-β1 treatment significantly impaired isoproterenol (ISO)-induced relaxation of carbachol-stimulated, isolated HASM cells. This single-cell mechanical hyporesponsiveness to ISO was corroborated by sustained increases in myosin light chain phosphorylation. In TGF-β1–treated HASM cells, ISO evoked markedly lower levels of intracellular cAMP. These attenuated cAMP levels were, in turn, restored with pharmacological and siRNA inhibition of phosphodiesterase 4 and Smad3, respectively. Most strikingly, TGF-β1 selectively induced phosphodiesterase 4D gene expression in HASM cells in a Smad2/3-dependent manner. Together, these data suggest that TGF-β1 decreases HASM cell β(2)-agonist relaxation responses by modulating intracellular cAMP levels via a Smad2/3-dependent mechanism. Our findings further define the mechanisms underlying β(2)-agonist hyporesponsiveness in asthma, and suggest TGF-β1 as a potential therapeutic target to decrease asthma exacerbations in severe and treatment-resistant asthma.

Background: Surgical aortic valve replacement may be complicated by significant perioperative bleeding. TAVR is a less invasive procedure, however bleeding may still occur related to periprocedural complications and anti-thrombotic therapy. We sought to compare baseline characteristics, hemodynamic parameters and clinical outcomes following TAVR between Jehovah’s witness (JW) patients who decline the use of blood products, and non-JW patients. Methods: Demographic, echocardiographic, and hemodynamic data of 245 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR at our institution between January 2013 and December 2015 were analyzed at baseline and at 30 day follow-up. Results: 10 patients were identified as JW refusing blood transfusion. None of the JW patients received blood products. JW and non-JW patients did not differ in respect to hemodynamic or echocardiographic parameters at baseline or 30 days post TAVR, including: blood pressure, heart rate, valve area, gradient, valvuloarterial impedance, cardiac output, stroke volume and ejection fraction. Baseline hemoglobin was higher in the JW versus non-JW groups, respectively (12.76 vs. 11.62 mg/dL p=0.045) and this was sustained at follow-up. Clinical outcomes were similar at 30 days between JW and non-JW patients, notably major bleed (10% vs 8.97%, respectively; p=0.91, defined as a clinical bleeding event with hemoglobin decrease > 2g/dL or transfusion of > 2 units of whole blood/red cells ) and 30 day mortality (0% vs 6.41%, respectively; p=0.19). Conclusion: JW patients were found to have similar hemodynamic and clinical outcomes up to 30 days. TAVR may be considered a reasonable treatment option for patients with symptomatic severe aortic stenosis who refuse transfusion of blood products.

Video Surveillance systems are used to monitor, observe and intercept the changes in activities, features and behavior of objects, people or places. A multimodal surveillance system incorporates a network of video cameras, acoustic sensors, pressure sensors, IR sensors and thermal sensors to capture the features of the entity under surveillance, and send the recorded data to a base station for further processing. Multimodal surveillance systems are utilized to capture the required features and use them for pattern recognition, object identification, traffic management, object tracking, and so on. The proposal is to develop an efficient camera placement algorithm for deciding placement of multiple video cameras at junctions and intersections in a multimodal surveillance system which will be capable of providing maximum coverage of the area under surveillance, which will leads to complete elimination or reduction of blind zones in a surveillance area, maximizing the view of subjects, and minimizing occlusions in high vehicular traffic areas. Furthermore, the proposal is to develop a video summarization algorithm which can be used to create summaries of the videos captured in a multi-view surveillance system. Such a video summarization algorithm can be used further for object detection, motion tracking, traffic segmentation, etc. in a multi-view surveillance system.

Introduction Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support Case Report We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases; case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics. Summary Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers; this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

Introduction We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation. Case Report 57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20th . She failed an extubation trial and underwent tracheostomy on July 23rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1. Summary Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

Introduction Transthyretin (TTR) cardiac amyloidosis is an underrecognized cause of cardiomyopathy in adultss, most commonly causing HFpEF. Herein we describe a patient with evidence of concurrent TTR cardiac amyloidosis and amyloid light-chain (AL) amyloidosis of the foregut. Case presentation A 70-year-old male with history of hypertension, peripheral neuropathy, lumbar spinal stenosis presented in January 2018 with abdominal pain and melena. Laboratory testing was significant for iron deficiency anemia. He underwent EGD and was found to have AL amyloidosis on gastric and duodenal biopsy. Serum protein electrophoresis showed paraprotein of 0.1 g/dL, and bone marrow aspirate showed 9% plasma cells. Skeletal survey showed absence of lytic lesions. TTE showed LV hypertrophy with LVEF 55% and global longitudinal strain at -19.4%. Systemic therapy with three cycles of Cyclophosphamide, Bortezomib, and dexamethasone (CyBorD) was planned, but he did not complete the third cycle due to insurance issues. In May 2019, he presented with hematemesis. Upper endoscopy showed thickened gastric and duodenal mucosa with active bleeding. Hemostasis was achieved after epinephrine injection and clipping. Troponin I was elevated at 0.2 ng/mL. TTE revealed LVEF 50%, grade I diastolic dysfunction, and abnormal global longitudinal strain at -11.5%. He was restarted on four cycles of CyBorD from June to October 2019. In September 2019, stress echocardiography showed worsening LVEF of 33% without evidence of ischemia. He did not endorse any heart failure symptoms. However, he was not verythat physically active. He had repeat EGD in November 2019 that showed persistent amyloid of the foregut on biopsy. In December 2019, Cardiac MRI showed no LGE. Technetium Pyrophosphate imaging in January 2020 showed grade 3 cardiac uptake, and heart to contralateral chest ratio uptake of 1.54. Genetic testing was negative for hereditary ATTR. Decision-making Findings on Technetium Pyrophosphate scan were suggestive of TTR cardiac amyloidosis. He refused an endomyocardial biopsy. Given the worsening heart failure and highly positive technetium pyrophosphate scan, he was started on tafamidis for TTR amyloidosis. Conclusions TTR cardiac amyloidosis is an underrecognized cause of cardiomyopathy. Other signs and symptoms that can lead to investigation for the diagnosis of amyloidosis include neuropathy and lumbar spinal stenosis. Noninvasive testing features of TTR cardiac amyloidosis include diffuse subendocardial or transmural LGE on cardiac MRI, and grade 2/3 uptake or heart to contralateral chest ratio >1.5 on the more sensitive technetium pyrophosphate scan. Endomyocardial biopsy can be done if technetium pyrophosphate scan is equivocal or if symptoms remain highly suggestive of amyloidosis with prior negative testing. It is also important to exclude AL cardiac amyloidosis as the treatment is different. Herein we described a rare case of concurrent TTR cardiac amyloidosis and AL amyloidosis of the foregut.

Introduction Optimal LVAD speed should be adjusted to adequately unload the left ventricle. Historic parameters such as septal position, degree of mitral regurgitation, and Aortic Valve opening have been used as surrogates for optimal pump speed in previous generation pumps. Our program has used hemodynamic ramp studies to optimize Pressure-Flow relationships and minimize wedge pressure independent of echo parameters. We share our experience with patients maintained at higher speeds than reported in the literature. Objective Examine the effects of higher pump speed in patients with Heartmate 3 LVADs. Methods A retrospective chart review of all the patients receiving LVADs at single center was performed. All patients who had Heartmate 3 implant between October 2018 and January 2020 were included (n= 38) Patients were divided into High-Speed group consisting of patients with speeds > 5600 rpm (n=20) and Low-Speed group, Results (Table 1): The absolute number of readmissions at 3-month visits was lower in the high-speed group (3 vs 12), but it was statistically insignificant (p 0.238). Similarly, the high-speed group had improved KCCQ scores (16 vs 12, p=0.55) that was not statistically significant. The high-speed group had a larger number of patients with elevated creatinine at the time of implant, most of these patients improved in 3 months (8 out of 10) as compared to the low-speed group which saw an upward trend in creatinine post-implant. Conclusion While little has been published on optimal pump speed in the Heartmate 3, Pressure-Flow curves suggest a clear advantage of running continuous flow pumps at higher RPMs. Unfortunately, our sample size is retrospective and underpowered, however, there appears to be a trend towards better outcomes in a small population maintained at higher pump speeds. A larger, and ideally prospective clinical trial to find optimal pump speeds for patients may provide insight into this issue and improve outcomes post-implant.

Introduction Left ventricular assist devices (LVADs) are well-accepted therapy for patients with advanced heart failure. There exist very few absolute contraindications to LVAD implantation. Many centers are tasked with creating criteria for inclusion and exclusion based on guidelines. This potentially leads to a wide variation in therapy delivery. We examined a single center experience with patients who were denied an LVAD elsewhere but were granted one at our program. Case series We reviewed all LVADs implanted at our center and identified 6 patients out of 45 implanted who presented for a 2nd opinion after initial denial. Table 1 describes the characteristics of the 6 patients and how all the concerns were addressed. We used Kansas City Cardiomyopathy Questionnaire and number of readmissions post-implant (Table 2) to assess outcomes. Discussion Though hard to generalize, the majority of patients were denied initially due to psycho-social barriers. More importantly, in these 6 patients, our 6- month evaluation suggested an improvement in the KCCQ score and a reduction in readmissions. Based on these 6 patients, noncompliance, lack of social support and signs of RV failure/renal dysfunction were the general reasons for rejection from the initial evaluation. However as suggested by our dataset, most of these barriers could be overcome with counseling, task-driven follow up and improvement in perfusion. Furthermore, presumed permanent renal dysfunction improved post-LVAD suggesting a reversible cardiorenal physiology. Our 6-month survival and readmission data exceeds INTERMACS benchmarks in DT implanting centers. Conclusions The selection criteria for LVAD remains a somewhat subjective and center-specific process with guiding principles that provide few absolute contra-indications. Though psycho-social barriers remain, as pumps become easier to manage and with a better side effect profile, it is plausible that historic barriers to implant should be re-evaluated on a regular basis with the intent of helping more patients with life-saving surgery. Societal guidelines and research should begin to explore the possibility of improved outcomes in higher-risk patients.

Background Extracorporeal membrane oxygenation (ECMO) utilization in children is recommended in refractory septic shock. However in adults there are no official recommendation to guide this treatment. Most of the existing evidence consists of small observational and single center experiences. We aimed to investigate the trend of use and outcomes of ECMO in patients with combined septic and cardiogenic shock. Methods We queried the unweighted national inpatient sample (NIS) for patients older than 18 years old, who carried both diagnoses of septic shock and cardiogenic shock during index hospitalization and received ECMO treatment for the years 2004-2017 using ICD-9&10 codes. Results We identified 29,178 patients with combined septic and cardiogenic shock in between 2004 and 2017. Of those, 424 (0.1%) patients underwent ECMO. There was a statistically significant increasing trend of ECMO use over the years of study (Std. J-T Statistic 4.338, p Conclusion ECMO is being increasingly used in patients with combined septic and cardiogenic shock, more data is needed to further guide this treatment modality in this patient population.

Cardiac sarcoidosis (CS) and arrhythmogenic right ventricular dysplasia (ARVD) are associated with ventricular arrhythmias and may have similar clinical presentations. We present a case initially diagnosed as ARVD, subsequently confirmed to be cardiac sarcoidosis. A 56 year old male was found

Risk stratification of patients with aortic stenosis (AS) is important especially in high-risk asymptomatic patients, patients with atypical symptoms, and those with symptoms but with a high surgical or procedural risk. Current American College of Cardiology/American Heart Association guidelines for indications to proceed with aortic valve replacement (AVR) for AS are the presence of symptoms because of AS, a left ventricular (LV) ejection fraction of

Due to miniaturization of hardware and availability of low-cost, low-power sensors, Wireless Sensor Network and Multimedia Sensor Network applications are increasing day by day. Each application has a specific quality of service and experience requirements. The design of routing and MAC protocol which can fulfill the requirements of the application is challenging given the constrained nature of these devices. Considerable efforts are directed towards the design of energy efficient QoS-aware routing protocols. In this article, we present state of the art review of routing protocols for Wireless Multimedia Sensor Networks while addressing the challenges and providing insight into research issues.

Purpose Left ventricular assist devices (LVADs) are a popular option for left ventricular support in bridging patients to heart transplantation or as destination therapy. However, the effect of heart failure etiology on outcomes after LVAD implantation has not yet been elucidated. Methods Between 2008 and 2018, a total of 549 patients with either ischemic cardiomyopathy (ICM) or nonischemic cardiomyopathy (NICM) underwent implantation of a continuous-flow LVAD our institution. ICM was defined by history of myocardial infarction or revascularization, coronary angiography showing ≥75% stenosis of the left main or proximal left anterior descending coronary arteries or ≥75% stenosis of two or more epicardial vessels. We identified 301 (54.8%) patients with NICM and 248 (45.2%) patients with ICM, and compared postoperative survival and adverse events in patients with ICM versus NICM. Results NICM patients were more likely to be female (22.9% vs 17.8%, p=0.08). Survival was similar between both groups with 30 day, 6 month, and 1 year survivals of 93%, 81%, and 72%, respectively, for ICM patients versus 91%, 81%, and 74%, respectively, for NICM patients (p=0.5) (Figure 1). Etiology of heart failure was not an independent predictor of survival in multivariate logistic regression analysis (p=0.84). There was no significant difference in adverse events including stroke, sepsis, or pump infection between the two groups. Conclusion The etiology of heart failure did not appear to significantly affect outcomes after LVAD implantation.

Purpose The gold standard for anticoagulation in patients with continuous flow left ventricular assist device (CF-LVADs) is warfarin. However, many patients fail warfarin therapy due to thromboembolic and bleeding events. Warfarin requires regular monitoring and dosage adjustments, and is associated with significant patient time outside recommended therapeutic INR range. Novel oral anticoagulation (NOAC) has been shown to be non-inferior compared to warfarin in stroke prevention with less intracranial hemorrhage in patients with atrial fibrillation. In this study, we sought to evaluate the safety and efficacy of NOACs in patients with CF-LVADs after failed warfarin therapy. Methods Patients who underwent CF-LVAD insertion between 2008 and 2018 were identified in a single-center database. 7 patients with either HeartMate II or HeartWare were switched from warfarin to a NOAC, either apixaban or rivaroxaban, were included. Occurrence of stroke, non-CNS embolism, pump thrombosis, and major GI bleeding or intracranial hemorrhage on warfarin and NOAC were evaluated. Results 5 of 7 patients were male, with an average BMI of 30. Common comorbidities were hypertension (100%), diabetes mellitus (57%) and ischemic cardiomyopathy (57%). There were a total of 3968 patient days on warfarin and 1459 patient days on a NOAC. Patients on warfarin therapy spent an average time of 30% within a therapeutic INR range. The rates of complications under warfarin versus NOAC therapy were: strokes 0.019 vs. 0 /patient-year, non-CNS embolism 0.019 vs. 0 /patient-year, pump thrombosis 0.01 vs. 0 /patient-year, major GI bleeding 0.02 vs. 0.07 /patient-year, and intracranial hemorrhage 0.019 vs. 0 /patient-year.(Table 1). Conclusion Increased complication rates and poor time in therapeutic INR range were present in patients receiving warfarin therapy after CF-LVAD insertion. NOAC therapy with apixaban or rivaroxaban may be a viable alternative. However, large prospective studies are necessary to confirm these results.

Thymic carcinoma is a rare, aggressive disease with low 5-year survivals. We undertook this study to identify factors that impact prognosis and to better define the relationship between survival and surgical intervention.We queried the Surveillance, Epidemiology, and End Results cancer database and identified patients with thymic carcinoma. We performed univariate and multivariate analyses to identify factors prognostic for survival, focusing on demographic, tumor, and treatment variables.For 290 patients with thymic carcinoma, the median survival was 48 months with 5-year survival of 30%. In multivariate analysis, type of surgical therapy (none, incomplete excision, complete thymic excision, debulking), Masaoka stage, and sex were important determinants of survival. Patients who underwent complete thymic excision had a significantly longer median survival than those who did not receive surgical therapy (105 versus 29 months; p0.001). In patients who underwent complete thymic excision, Masaoka stage and race were important determinants of survival in multivariate analysis.Complete thymic excision is the preferred primary treatment for thymic carcinoma. Masaoka stage has significant prognostic implications for all patients, including those who undergo complete thymic excision.

Background Diagnosis of constrictive pericarditis (CP) can be challenging. It can be nearly impossible to distinguish CP from other causes of right heart failure. Although various imaging modalities help in the diagnosis, no test is definitive. Several reviews have addressed the role of various imaging techniques in the diagnosis of CP but a systematic review has not yet been published. Objective Our intention was to study the ability of various non-invasive imaging modalities to diagnose CP in patients with surgically confirmed disease and to apply our findings to develop a clinically useful diagnostic algorithm. Methods A PubMed (NLM) search was performed with MeSH term “constrictive pericarditis”. Original articles that investigated the ability of various cardiovascular imaging modalities to noninvasively diagnose surgically confirmed CP were included in our review. Investigations that included any cases without surgical confirmation were excluded. Results The PubMed search yielded 3001 results with MeSH term “constrictive pericarditis” (January 8, 2016). We identified (40) studies on CP that matched our inclusion criteria. We summarized our results sorted by individual non-invasive CV imaging modalities – echocardiography, cardiac computed tomography (CT), and magnetic resonance imaging (MRI). Under each imaging modality, we grouped our discussion based on different parameters useful in CP diagnosis. Conclusions In conclusion, contemporary diagnosis of CP is based on clinical features and echocardiography. Cardiac MRI is recommended in patients where echocardiography is not diagnostic. Both cardiac MRI and CT can guide surgical planning but we prefer MRI as it provides both structural and functional information.

Paradoxical low flow-low gradient aortic stenosis (PLF-LG AS) is characterized by low stroke volume and gradient despite a normal ejection fraction (EF), and is associated with poorer outcomes. The mechanism of low flow is incompletely understood and is presumed to be related to restrictive filling