Sex and Age Characteristics in Acute or Chronic Myocarditis A Descriptive, Multicenter Cohort Study

BACKGROUND

Understanding the clinical features of myocarditis in various age groups is required to identify age-specific disease patterns.

OBJECTIVES

The objective of this study was to examine differences in sex distribution and clinical outcomes in patients with myocarditis of various ages.

METHODS

Patients with acute or chronic myocarditis in 3 centers in Berlin, Germany from 2005 to 2021 and in the United States (National Inpatient Sample) from 2010 to 2019 were included. Age groups examined included "prepubescent" (below 11 years for females and below 13 years for males), adolescents (11 [female] or 13 [male] to 18 years), young adults (18-35 years), "middle-aged adults" (35-54 years), and older adults (age >54 years). In patients admitted to the hospital, hospital mortality, length of stay, and medical complication rates were examined.

RESULTS

Overall, 6,023 cases in Berlin and 9,079 cases in the U.S. cohort were included. In both cohorts, there were differences in sex distribution among the 5 age categories, and differences in the distribution were most notable in adolescents (69.3% males vs 30.7% females) and in young adults (73.8% males vs 26.3% females). Prepubescent and older adults had the highest rates of in-hospital mortality, hospital length of stay, and medical complications. In the Berlin cohort, prepubescent patients had higher levels of leukocytes (P < 0.001), antistreptolysin antibody (P < 0.001), and NT-proBNP (P < 0.001) when compared to young adults.

CONCLUSIONS

In this study, we found that sex differences in myocarditis and clinical features of myocarditis were age-dependent.

Left-ventricular unloading in extracorporeal cardiopulmonary resuscitation due to acute myocardial infarction - A multicenter study

BACKGROUND

Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI).

METHODS

This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed.

RESULTS

95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31-0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50-1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57-2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading.

CONCLUSIONS

LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.

Treatment with Impella and veno-arterial extracorporeal membrane oxygenation during cardiac arrest on survival in a multicenter cohort

Background

International organisations advocate the use of extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with therapy-refractory cardiac arrest [1–3]. Although VA-ECMO allows for full circulatory support, it is inherent to increased left ventricular (LV) pressure due to retrograde aortic perfusion, which may hamper myocardial recovery and aggravate pulmonary oedema. In order to mitigate these negative sequelae, adjunct LV unloading with an Impella microaxial flow pump may be considered. The effects of concomitant treatment with VA-ECMO and Impella (ECMELLA) in patients with therapy-refractory cardiac arrest due to acute myocardial infarction (AMI) remains unclear.

Objectives

To the best of our knowledge this is the first study to investigate whether treatment with ECMELLA is associated with improved 30-day mortality rate in patients with therapy-refractory cardiac arrest caused by AMI, compared to treatment with VA-ECMO alone.

Methods

Patients treated with ECMELLA were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram (ECG) rhythm, cardiac arrest location (out-of-hospital or in-hospital) and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Multiple sensitivity analyses on patient demographics and cardiac arrest parameters were performed.

Results

95 adult patients from three tertiary care centers were included, out of whom 34 pairs were PS-matched. ECMELLA treatment was associated with 47% decreased 30-day mortality risk [95% Confidence Interval (CI) 0.31–0.91, P=0.021], 71% prolonged hospital [95% CI 1.50–1.95, P&lt;0.001] and 81% prolonged ICU LOS [95% CI 1.57–2.08, P&lt;0.001]. Kaplan-Meier analyses (Figure 1) and multiple sub-group analyses (age, sex, initial ECG rhythm, Charlson comorbidity index, body mass index, SAVE score, cardiac arrest location, lactate and pH levels) confirmed survival benefits in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from ECMELLA therapy. Moreover, LV ejection fraction strongly improved in the ECMELLA group between ICU admission and ICU discharge from 15% to 40%, compared 15% and 20% in the VA-ECMO group.

Conclusion

In this multicenter propensity score-matched cohort of patients with ECPR during therapy-refractory cardiac arrest caused by AMI, treatment with ECMELLA was associated with improved survival compared to treatment with VA-ECMO alone. These findings support current guideline recommendations on early evaluation of ECPR in well selected patients with therapy-refractory cardiac arrest. A clinical trial is urgently needed to further evaluate the role of LV unloading in patients with therapy-refractory cardiac arrest.

Funding Acknowledgement

Type of funding sources: None.

Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients

Background

The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs.

Purpose

To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients.

Methods

Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs.

Results

30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15–12.27, P<0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15–1.58, P<0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P<0.001). Of note, readmitted and non-readmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%).

Conclusion

Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge.

Funding Acknowledgement

Type of funding sources: None.

[Plasma-cell osteomyelitis of the thoracic spine--a case report]

The authors report the case of a young patient suffering from plasmacellular osteomyelitis of the thoracic spine, a unusual localisation of this type of chronic osteomyelitis. They discuss the role of imaging diagnostic modalities in this disease, focussing on MRI.

[Local catheter-mediated lysis of the femoral artery: rt-PA versus urokinase]

Percutaneous, catheter-mediated lysis was performed on 56 patients with acute to subacute thrombosis of the superficial femoral artery (Fontaine stage IIb to IV). One half of the patients received rt-PA, the other half urokinase. The clinical parameters of the two groups of patients were largely the same. The therapeutical results were, at about the same treatment costs, better in the rt-PA patients group, in particular with regard to the considerably shorter average treatment period, which lasted on the average for 2 hours in the rt-PA group, vs. 6 hours in the urokinase group. The recanalisation rate was also higher in the rt-PA group (86%) vs. 75% in the urokinase group.

[Importance of muscle clearance for follow-up after percutaneous transluminal angioplasty]

Muscular clearance as the maximum blood flow in the M. tibialis anterior was determined with 133Xe in 78 patients before and after percutaneous transluminal angioplasty (PTA) of the femoral artery. The increase in maximum blood flow after successful PTA was 33.1%, which is consistent with the results of other investigators. In contrast to the clinical findings (OAD state according to Fontaine) obtained before and after PTA, the muscle clearance worsened in 42.6% of the cases studied. In 85% of the patients, the angiographic findings (stenosing arteriosclerosis of the A. tibialis anterior) explained the cause of this observation; these findings should therefore be available before the muscle clearance is studied.

[Tuberculosis of the pelvic girdle]

Between 1955 and 1980 a total of 67 patients (42 female, 25 male) with advanced tuberculosis of the pelvic girdle underwent surgery at the authors' clinic. In 43 patients the sacroiliac joint was affected (in 2 cases bilaterally), in 11 the ischium, in 9 the pubic bone, and in 2 each the ilium and the sacrum. The average of the patients (who included 4 migrant workers) was 44. The youngest patient was 8, the oldest 67 years old. The average interval between the onset of complaints and diagnosis was 4.6 years (minimum 1 month, maximum 20 years). Thirty-eight of the patients had already had treatment for an organic or osteoarticular tuberculosis. Although 24 (35.8%) of the patients were simultaneously suffering from a florid, specific infection localized elsewhere, and abscesses, fistulas, or a combination of these were identified in 40 patients (59.7%), only 17 (25.4%) were in slightly impaired general condition, and in over one-half of the patients, the hourly blood sedimentation rate was normal or only slightly elevated (up to 20 mm n.W.). In 9 cases (13.4%) the only pointers to tuberculosis were the patient's history, clinical and radiological findings, and the subsequent evolution of the disease. In these cases the diagnosis could not be confirmed either by histologic or by bacteriologic study of focal tissue. In 67 patients, 66 osseous foci were removed and in 2 cases merely an abscess (after an average of 2-3 weeks' tuberculostatic therapy), the bone cavities were filled with a mixture of heterogeneous or autogenous spongiosa and tuberculostatics or merely with chemotherapeutic drugs, and primary closure of the wound was performed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of angiography in the diagnosis of giant cell arteritis]

Two cases of giant cell arteritis are reported. Angiography was performed to obtain information about the extent of arterial lesions (case 1). In the second case angiography was a guide to diagnosis. Differential diagnostic considerations and the value of angiographic examination are discussed.

[Thromboxane concentrations in the arterial blood of cigarette smokers]

Thromboxane concentrations were investigated in the arterial plasma of 44 patients (25 smokers, 19 nonsmokers) with chronic obstructive arterial disease (COAD) of the lower extremities, documented by angiography. The thromboxane levels were measured by radioimmunoassay. The results indicate that smokers with COAD have significantly higher thromboxane levels than nonsmokers with COAD. The potential effect of nicotine on thromboxane is discussed.

[Intravenous subtraction angiography as a control examination following blood vessel surgery]

21 patients were examined after different, mostly peripheral vessel operations by intravenous angiography in combination with photographic subtraction. In all cases there was a diagnostic reliability on the documented findings. Structure of vessel-side, morphology of stenoses, formation of a collateral circulation, functioning of bypasses and arteriovenous shunts could be judged sufficiently by the conventional intravenous subtraction angiography (ISA). As a convenient method for the control of the arterial vessel side after vessel operation and angioplasty, the ISA is a suitable method when the digital subtraction angiography is not available. The image quality of the ISA at present is at least equivalent to that of the DVSA .

[Primary diaphyseal tuberculosis of the long bones]

Primary tuberculosis of the diaphysis of long bones is extremely rare. In the last 27 years (1955-1982) we observed one female patient with this infection in the shaft of the right femur and one male patient with symmetrical involvement of the tibiae in our Clinic. In both cases, the diagnosis was confirmed by histological examination of the lesions. The relevant literature is reviewed concerning the frequency, age incidence, localisation, clinical features, treatment, prognosis and differential diagnosis of tuberculosis of the diaphysis.

[Isolated tuberculosis of the sternum]

Isolated tuberculous foci of the sternum are rare. In a period of 26 years (1955 to 1981) we have treated ten sternal lesions surgically in our clinic. Eight of these were tuberculous. The clinical material (three females, five males) is described, including diagnostic and therapeutic details. The frequency, localisation, clinical features, diagnosis, treatment, prognosis and differential diagnosis of specific sternal infections are discussed and the relevant literature is reviewed.

[Errors in interpretation of myocardial perfusion scintigrams with 201thallium due to poor quality scans (author's transl)]

Five myocardial scintigrams are shown, where there were difficulties in interpretation. In the first three examples, there was excessive distance of the collimator from the heart, resulting in poor quality scintigrams and leading to possible misinterpretation. Two further myocardial scintigrams are shown in patients who had eaten before the scan. In a further patient, there was insufficient cardiac ergometric stress. The problem is discussed briefly.

[Craniolacunia ("Lückenschädel") as an isolated finding (author's transl)]

Case report of congenital craniolacunia ("Lückenschädel" or lacunar skull) only associated with several noncerebral malformations but lacking the CNS findings usually associated with this condition, such as dysraphism. Presentation and discussion of etiology and prognosis of this anomaly and its differential diagnosis.

[Improved diagnosis in percutaneous transhepatic cholangiography (PTC) (author's transl)]

PTC is a good radiographic method in the diagnosis of cholestasis. Complications are rare, primarily due to the ultra-thin Chiba needle. For penetrating the liver we recommend to keep a distance of at least 4 cm between needle and spine (measured on the monitor). Our experience has shown routine liver tomography to be very helpful. Furthermore, delayed radiography can show extrahepatic bile ducts not seen on initial films.