Background and aims Heart failure is one of the leading causes of morbidity and mortality in the United States. The advent of left ventricular assist devices (LVAD) has improved the survival and quality of life in patients with end stage heart failure. Gastrointestinal bleeding (GIb) remains one of the limitations of LVADs. Methods A single center, retrospective review of records was performed for patients who underwent LVAD implantation between 2010 and 2015. All patients who survived more than 30 days were followed till March 2016 and are described below. Results A total of 79 patients were included in the study. The rate of GIb was 34.1% (27 patients) with a mean time to bleed of 267 days. Older patients were more likely to bleed. Upper GI bleeding was the source of bleeding in 54% patients. Arteriovenous malformations (AVM) were the source of bleeding in 74% bleeders and 80% of these patients had de novo AVM formation. 14/27 (51%) patients had a re-bleeding event. Thrombotic events were 4.5 times more likely to occur in patients who also had a GI bleed. Conclusions GI bleeding in LVAD patients is common with the source of bleeding more commonly being in the upper GI tract. GI bleeding may occur as early as 10 days post procedure, despite previous negative screening endoscopies. There is an increased risk of thrombotic events in patients who have experienced a GI bleed.

Left atrial appendage closure with the WATCHMAN device is an alternative to chronic oral anticoagulation for thromboembolic prophylaxis in atrial fibrillation patients. Left atrial device-related thrombus (DRT) has been described in the first year after implant with an incidence of ~6%. A 79-year-old man underwent WATCHMAN device placement in 2006. Routine protocol specified follow-up transesophageal echocardiograms (TEE) at 6 weeks, 6 months, and 1 year following implant showed no evidence for DRT or peri-device flow. A decade after device implant, the patient presented with severe symptomatic aortic stenosis and underwent repeat TEE, which revealed a 21 mm × 18 mm DRT on the LA aspect of the WATCHMAN device. He was prescribed apixaban 5 mg po BID. A TEE performed 111 days later demonstrated marked diminution in the DRT (9 mm in diameter). This case demonstrates that WATCHMAN DRT may occur late following implantation.

Purpose of review To illustrate successful reversal of hypertriglyceridemia using a very-low-carbohydrate ketogenic diet in conjunction with intermittent fasting in two patients. Recent findings Hypertriglyceridemia remains an important component of residual risk for atherosclerotic cardiovascular disease. Current guidelines from the AHA/ACC recommend the initiation of a very-low-fat diet to treat persistently elevated triglycerides, whereas the National Lipid Association argues that a very-low-carbohydrate, high-fat diet is contraindicated in severe hypertriglyceridemia. In contrast, we report resolution of two cases of severe hypertriglyceridemia with implementation of very-low-carbohydrate ketogenic diets and intermittent fasting. Summary Here, we describe two patients who have demonstrated substantial reductions in serum triglycerides, effectively reversing severe hypertriglyceridemia using unconventional dietary methods. Although anecdotal, these cases point to a critical lack of flexibility in current dietary guidelines that hinder their application in clinical practice.

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The prevalence of radial access for transradial catheterization remains low in the US, occurring in only 28% of cases in the National Cardiovascular Data Registry (NCDR®) CathPCI®. It is unknown whether the low adoption rate has been influenced by patient characteristics, or is more operator dependent. In a 10-center study, we compared clinical and demographic characteristics among 323 radial and 1506 femoral access PCIs performed by 65 interventionists capable of radial percutaneous intervention (PCI). We created a hierarchical logistic regression model to identify operator and patient characteristics associated with radial PCI and the median rate ratio to quantify the variation across operators. A subset was interviewed to assess health literacy and preferences in shared medical decision-making. Radial access was used in 17.7% of patients. Patient factors associated with lower rate of radial PCI were prior PCI (33.4% vs 41.4% P=0.008), history of Coronary Artery Bypass Graft (8.4% vs 23.0% P <0.001) and Chronic Total Occlusion PCI (10.2% vs 17.9% P <0.001). Operator characteristics associated with lower rate of radial PCI are being older, being longer in practice, lower number of publications and Southern practice location. The range of radial use across operators was 1– 99% and the median rate ratio was 1.97. Patients with radial access had lower health literacy, as assessed by the REALM score (6.6±2.6 vs 7.1±2.0, p= 0.03) but did not differ in their preferences for shared decision-making. In conclusion our study demonstrates a high degree of variability of radial access for PCI among different operators, with few differences in patient characteristics, suggesting that improvement efforts should focus on operators.