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Background Right ventricular (RV) dilation has been used to predict adverse outcomes in acute pulmonary conditions. It has been used to categorize the severity of novel coronavirus infection (COVID-19) infection. Our study aimed to use chest CT-angiogram (CTA) to assess if increased RV dilation, quantified as an increased RV:LV (left ventricle) ratio, is associated with adverse outcomes in the COVID-19 infection, and if it occurs out of proportion to lung parenchymal disease. Results We reviewed clinical, laboratory, and chest CTA findings in COVID-19 patients (n = 100), and two control groups: normal subjects (n = 10) and subjects with organizing pneumonia (n = 10). On a chest CTA, we measured basal dimensions of the RV and LV in a focused 4-chamber view, and dimensions of pulmonary artery (PA) and aorta (AO) at the PA bifurcation level. Among the COVID-19 cohort, a higher RV:LV ratio was correlated with adverse outcomes, defined as ICU admission, intubation, or death. In patients with adverse outcomes, the RV:LV ratio was 1.06 ± 0.10, versus 0.95 ± 0.15 in patients without adverse outcomes. Among the adverse outcomes group, compared to the control subjects with organizing pneumonia, the lung parenchymal damage was lower (22.6 ± 9.0 vs. 32.7 ± 6.6), yet the RV:LV ratio was higher (1.06 ± 0.14 vs. 0.89 ± 0.07). In ROC analysis, RV:LV ratio had an AUC = 0.707 with an optimal cutoff of RV:LV ≥ 1.1 as a predictor of adverse outcomes. In a validation cohort (n = 25), an RV:LV ≥ 1.1 as a cutoff predicted adverse outcomes with an odds ratio of 76:1. Conclusions In COVID-19 patients, RV:LV ratio ≥ 1.1 on CTA chest is correlated with adverse outcomes. RV dilation in COVID-19 is out of proportion to parenchymal lung damage, pointing toward a vascular and/or thrombotic injury in the lungs.

Introduction: Distinct pathophysiologic differences exist among heart failure (HF) patients depending on baseline left ventricular ejection fraction (LVEF) and degree of LVEF recovery to medical therapy; however, differences in clinical outcomes among these patients remain unclear. Hypothesis: We hypothesized that patients with HF and mid-range EF (HFmrEF) would have lower all cause and HF hospitalizations compared to HFpEF and HFrEF patients. Methods: We identified 9,428 patients between 2009-2018 with ICD diagnosis of HF with a baseline and 1-year follow-up echocardiogram. We created 9 subgroups based on initial and follow-up ejection fraction (LVEF defined as preserved >50%; midrange 40-50% and reduced Results: A total of 424 HFmrEF patients who maintained mid-range ejection fraction at follow-up were included in our analysis. HFmrEF patients were less likely to have pulmonary hypertension and more likely to have ischemic cardiomyopathy, coronary artery disease, hyperlipidemia compared to HFrEF and HFpEF (P Conclusions: Patients who have mid-range ejection fraction at diagnosis and at follow-up had lower all cause and HF hospitalizations and shorter length of stay when compared to HFrEF, recovered EF, and HFpEF patients. Further research is needed to determine the proper management of this group.

Introduction: Post-capillary pulmonary hypertension (PH) is diagnosed with rest hemodynamics and requires management of left heart disease. However, in subclinical PH and mixed PH (mixed pre- and post-capillary), it is imperative to identify a predominant post-capillary phenotype with exercise (aka. Pulmonary venous hypertension). Hypothesis: In suspected subclinical and mixed PH, greater left atrial volume index (LAVI; >35) and E/E’ (>8) on echocardiogram can reliably predict a predominant post-capillary PH with exercise, assessed with invasive cardiopulmonary exercise testing (iCPET). Methods: We reviewed clinical, echocardiographic and iCPET data for 37 patients undergoing exercise right heart catheterization and then analyzed the data with receiver operator curve (ROC) and area under the curve (AUC) analysis to estimate the different echo parameters to identify post-capillary PH. Results: Within the cohort, mean age (± SD) was 63.6±11.3 years, and 19 subjects were female (51%). On ROC analysis, LAVI and E/E’ had high predictive ability to identify a pulmonary venous hypertension response with exercise (AUC=0.860, p=0.003 for LAVI, and AUC=0.788, p=0.014) with optimal cut-offs identified as: LAVI >35 and E/E’ >8. These variables also notably had a significant association with PCWP/CO>2. To understand the hemodynamics associated with these differentiable echo features, we divided the overall cohort (n=37) into 2 groups: group 1 ( Abnormal-LA group ) =LAVI>35 and/or E/E’ >8, group 2 ( Normal-LA group )=LAVI≤ 34 and E/E’≤8. The LAVI in group 1 vs group 2 was: 44.3±15.2 vs 23.1±4.4 (p Conclusions: Among individuals with suspected PH, LAVI>35 and E/E’ >8 are reliable non-invasive markers to identify post-capillary PH. In a patient with a new diagnosis of PH based on screening echocardiogram, LAVI≤ 34 and E/E’≤8 may identify a patient who is likely to benefit from PH drugs.

Purpose Approximately half of all heart transplant programs utilize induction therapy during the early postoperative period. However, differences in survival using modern induction therapies have not been investigated in the current era. Methods We selected all adult patients from the United Network for Organ Sharing (UNOS) database who underwent first time heart transplantation between 2008-2017 and received either induction therapy with anti-thymocyte globulin (ATG; n= 3747) or basiliximab (n=5157) or had no induction treatment (n=10,485). Kaplan Meier curves and multivariable Cox models compared the differences in survival among all three groups. Results Mean age of patients was 53.5 years and 25.7% were females. In general, patients who received ATG had longer wait times on the waitlist, had slightly higher ischemic times and there were fewer male recipients with female donors in this group. Upon follow up, 4,236 patients died. Kaplan Meier curves as displayed (Figure) suggested improved survival for those who received ATG compared to Basiliximab. In multivariable models, compared to patients who received ATG, those who received Basiliximab had higher risk of death (hazard ratio 1.11; p 0.02). There were no statistical differences in survival when patients who received ATG were compared to those who did not receive any induction therapy. Conclusion In conclusion, induction therapy with ATG is associated with marginal survival benefit compared to induction therapy with basiliximab however there were no differences in long-term survival of patients who receive ATG when compared to those who did not receive any induction therapy.

Background Stress cardiomyopathy is characterized by transient myocardial dysfunction that mimics a myocardial infarction in the absence of obstructive coronary artery disease. The onset is frequently triggered by an acute illness or intense physical or emotional stress. Case Report We describe the case of a 47-year-old woman who was brought to the emergency department with acute onset shortness of breath while scuba diving. She was found to have acute pulmonary edema radiographically. Her troponins were noted to be positive. Initial echocardiogram showed basal hypokinesis with hyperkinesis of apex. She was treated with noninvasive ventilation and intravenous diuretic therapy and her symptoms significantly improved. She subsequently underwent cardiac catheterization which revealed nonobstructive coronary artery disease. An exercise stress echocardiogram was performed 2 days later that revealed resolution of the wall motion abnormality and no ischemia at high levels of exercise. A diagnosis of reverse stress (Takotsubo) cardiomyopathy was made based on Mayo Clinic Diagnostic criteria. ​Why Should an Emergency Physician Be Aware of This? This case brings to light the risk of stress cardiomyopathy in divers. The diagnosis should be considered in patients presenting with acute pulmonary edema during diving.

Introduction Non-invasive methods to identify phenotype of pulmonary hypertension (PH) remains a topic of interest. Cardiopulmonary exercise test (CPET) provides gas exchange (GX) parameters including end-tidal carbon dioxide (ETCO2) and ventilation of minute ventilation to carbon dioxide ventilation ratio (VE/VCO2). A direct correlation of these GX parameters with invasive hemodynamics can provide further insight into the ability of GX parameters to predict PH phenotype. Hypothesis Using a direct correlation of gas exchange parameters with invasive hemodynamics, we propose that in subjects with suspected PH, rest gas exchange parameters can reliably predict pulmonary vascular disease. Methods We reviewed clinical, echocardiographic and invasive CPET (iCPET) data for 41 patients. We then analyzed the data with receiver operator curve (ROC) to help estimate the area under the curve (AUC) of different gas exchange parameters to help define the hemodynamics of different PH groups and derive the most appropriate parameters to define PH. *p Results Among the overall cohort, mean age (± SD) was 63.9±11.35 years, and 20 subjects were female (49 %). The distribution of WHO groups of PH based on the final diagnosis among the overall cohort was: 8 patients WHO group I (19.5%), 21 patients WHO group II (51.2%), 3 patients WHO group III (7.3%), 1 patient WHO group IV (2.4%), and 8 patients had no evidence of rest or exercise PH (19.5%). For the purpose of analysis, we created three groups: 1) pulmonary vascular disease (PVD): combination of WHO group I, III and IV, 2) pulmonary venous hypertension (PVH): WHO group II, 3) Control: no PH group. On ROC analysis, rest and exercise ETCO2 and VE/VCO2 had equally high predictive ability to predict exercise PVR > 3 WU (rest ETCO2=0.806, exercise ETCO2=0.880, rest VE/VCO2=0.794, exercise VE/VCO2=0.820). Similar pattern of ETCO2 and VE/VCO2 was identified with prediction of rest PVR >3WU and WHO group I PAH. Based on the ROC analysis, we found that the ideal cutoffs (to predict rest PVR>3WU or exercise PVR>3WU or PVD group) were ≤30 mmHg for ETCO2 and ≥42 for VE/VECO2.Using these cutoffs, we created a scoring system of “rest-only” GX parameters (+1 for ETCO2 ≤30 and VE/VCO2 ≥42; and -1 for vice versa). Each patient would have a total score of -2, 0 or +2. The AUC for this rest-only scoring system to predict exercise PVR >3WU was 0.841. When applied to the whole cohort, score of -2 (n=14) included: 8 PVH and 5 with no PH, score of +2 (n=11) included 6 PVD (percentages shown in figure). Conclusions Among individuals with suspected PH, a composite gas exchange score with VE/VCO2 (≥42) and ETCO2 (≤30 mmHg) reliably predicts PVD.

This article reports a rare case of the use of low-dose ketamine infusion as an adjuvant to opioids to treat pain in sickle cell disease. A 31-year-old African-American male with history of sickle cell disease presented to the emergency department with complaints of chest tightness, multiple joint pain, and headache for 1 week. His vital signs and physical examination were unremarkable. His admission lab included hemoglobin of 8.4 g/dl, reticulocyte count of 16.3 %, bilirubin of 1.7 mg/dl, and LDH of 1,267 U/l. Chest X-ray showed middle and lower lobe opacity and interstitial thickening. He was treated for acute pain crisis and community-acquired pneumonia with intravenous fluids, supplemental oxygen, and intravenous levofloxacin. He was placed on fentanyl patient-controlled analgesia (PCA), oxycodone, ketorolac, and methadone with co-analgesic gabapentin and venlafaxine. Over the course of his hospitalization, his chest pain resolved, but the joint pains continued. He was then transferred to the ICU and was discharged a day later after 7 days of ketamine infusion. Ketamine is a noncompetitive antagonist at the N-methyl-d-aspartate (NMDA) receptor. This property has been shown to modulate opioid tolerance and opioid-induced hyperalgesia. There have been a very few published reports on the use of low-dose ketamine in sickle cell pain management. A PubMed search revealed four published articles (Table 1). Fourteen out of the 17 cases (82.35 %) who received ketamine infusion showed improvement in self-reported pain intensity and significant reduction in opioid dosage. Only one patient (5.9 %) developed serious side effect leading to discontinuation of the drug. A low-dose ketamine can be an option for pain control in sickle cell disease. Randomized trial is required to establish this benefit of ketamine over currently available therapies.