A low-dose thrombolytic infusion protocol for safe and successful treatment of left ventricular assist device thrombosis: a case series

Background

Pump thrombosis is a serious complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. In this study, we aim to report a novel protocol of an intermittent, low-dose, and slow infusion of tissue plasminogen activator (alteplase).

Case summary

We treated seven LVAD pump thrombosis events (HeartMate® II and HeartWare) in four patients with a median age of 52 years (31-63), and all were female. The protocol was applied from January 2015 to December 2018, and it consisted of an intermittent, low-dose, and slow infusion of systemic thrombolytic therapy in the intensive care unit. This therapy resulted in successful resolution of pump thrombosis in six out of seven events. Bleeding complication occurred in one patient, which included a ruptured haemorrhagic ovarian cyst and a small cerebellar intra-parenchymal haemorrhage. All patients were discharged home in a stable condition, except one patient who died during hospitalization because of severe sepsis, pump thrombosis with subsequent pump exchange, and multi-organ failure.

Discussion

A low-dose, prolonged, and systemic thrombolytic infusion protocol is an effective and relatively safe treatment that can lead to a sustained resolution of pump thrombosis with low bleeding complications and failure rates.

Evaluation of Right-Side Filling Pressure in Patients With Obesity With Heart Failure Using Handheld Ultrasound Score

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58 years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95] vs 0.69 [0.58 to 0.81], p = 0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95] vs 0.82 [0.71 to 0.93], p = 0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10 mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status.

Cardiac Contractility Modulation in Patients with Advanced Heart Failure: A Comprehensive Review of Literature

Heart failure is a significant cause of morbidity and mortality worldwide. Despite advancements in guideline-directed medical therapy and improvements in device-based therapies, patients with advanced heart failure have high rates of mortality regardless of ejection fraction. For patients with reduced ejection fraction who meet criteria, cardiac resynchronization therapy or implantable cardiac defibrillators are options available to improve outcomes. However, not all heart failure patients meet those criteria. Cardiac contractility modulation is an innovative therapy that serves to improve functional outcomes and quality of life, while also modifying pathologic gene expression and preventing further remodeling. In this article, we aim to discuss the major clinical trials investigating cardiac contractility modulation as a suitable therapy for patients with advanced heart failure.

Testosterone Replacement Therapy in Relation With Cardiovascular Disease in Cisgender Women and Transgender People

AIMS

This study aimed to investigate the association of testosterone replacement therapy (TTh) with risk of cardiovascular disease (CVD), and CVD-specific outcomes, in cisgender women and transgender population, and to determine whether this association varies by menopausal status.

METHODS

In 25 796 cisgender women and 1580 transgender people (≥30 years old) who were enrolled in the Optum's deidentified Clinformatics Data Mart Database (2007-2021), we identified 6288 pre- and postmenopausal cisgender women and 262 transgender people diagnosed with incident composite of CVD (coronary artery disease [CAD], congestive heart failure, stroke, and myocardial infarction). Prediagnostic prescription of TTh was ascertained for this analysis. Multivariable adjusted Cox proportional hazards models were used to examine the independent association of TTh with incident CVD.

RESULTS

We found a 24% increased risk of CVD (hazard ratio [HR] = 1.24; 95% CI, 1.15-1.34), 26% risk of CAD (HR = 1.26; 95% CI, 1.14-1.39), and a 29% risk of stroke (HR = 1.29; 95% CI, 1.14-1.45) after comparing cisgender women who used TTh with nonusers. Stratification by age group showed similar effects of TTh on CVD, CAD, and stroke. Among transgender people, TTh did not increase the risk of composite CVD, including by age stratification.

CONCLUSION

Use of TTh increased the risk of CVD, CAD, and stroke among cisgender women but not among transgender people. TTh is becoming more widely accepted in women, and it is the main medical treatment for transgender males. Therefore, use of TTh should be further investigated for the prevention of CVD.

Effect of statins and testosterone replacement therapy on incident cardiovascular disease among male hormone-related cancer survivors

Purpose

Statins and testosterone replacement therapy (TTh) have been previously linked with prostate, colorectal and male breast cancer (hereinafter we will refer as hormone related cancers [HRCa]), and cardiovascular disease (CVD). However, there is a poor understanding about the combined association of statins and TTh with incident CVD among HRCa survivors and a matched cancer-free cohort.

Methods

We identified 44,330 men of whom 22,165 were previously diagnosed with HRCa, and 22,165 were age-and index-matched cancer-free in SEER-Medicare 2007-2015. Pre-diagnostic prescription of statins and TTh prior to CVD development was ascertained for this analysis in the two matched cohorts. Weighted multivariable-adjusted conditional logistic regression models were used to evaluate the independent and combined associations of statins and TTh with CVD.

Results

We found that use of statins (OR = 0.51, 95% CI: 0.46-0.55) and TTh (OR = 0.81, 95% CI: 0.67-0.97) were each independently inversely associated with incident CVD in the overall sample. TTh plus statins was also inversely associated with CVD. Associations were similar in the matched cancer-free cohort. Among HRCa survivors, only statins and combination of TTh plus statins (OR = 0.60, 95% CI: 0.44-0.98) were inversely associated with CVD, but the independent use of TTh was not associated with CVD.

Conclusion

In general, pre-diagnostic use of statins and TTh, prior to CVD development, independently or in combination, were inversely associated with CVD in the overall, cancer-free population, and among HRCa survivors (mainly combination). Independent effects and combination of statins and TTh remained to be confirmed with specific CVD outcomes among HRCa survivors.

Outcomes of Transcatheter Aortic Valve Implant Among Patients With A Previous Coronary Artery Bypass Graft: A Nationwide Analysis

There is a paucity of data regarding the temporal trends and outcomes of transcatheter aortic valve implant (TAVI) among patients with a previous coronary artery bypass graft (CABG) surgery. We queried the Nationwide Readmissions Database (2016 to 2019) for hospitalized patients who underwent TAVI using the appropriate International Classification of Diseases, Tenth Revision procedural codes. A multivariable regression analysis was used to adjust for the patients' and hospitals' characteristics in comparing the study groups. The primary outcome was in-hospital mortality. The final analysis included 237,829 patients who underwent TAVI, of whom 42,671 (17.9%) had a previous CABG. During the study period, there was a decrease in the proportion of patients with previous CABG who underwent TAVI (21.0% in 2016 vs 15.5% in 2019, ptrend = 0.01), although there was no change in their in-hospital mortality rate (1.08% in 2016 vs 1.25% in 2019, ptrend = 0.43). Patients with a previous CABG were younger and less likely to be women than those without a previous CABG. TAVI among those with a previous CABG was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.79, 95% confidence interval [CI] 0.69 to 0.91), similar rate of ischemic stroke (aOR 0.81, 95% CI 0.71 to 0.93) and permanent pacemaker implant (aOR 1.00, 95% CI 0.93 to 1.05). Patients with a previous CABG had a lower all-cause 90-day readmission (odds ratio 0.95, 95% CI 0.94 to 1.06) but higher readmission for transient ischemic attack. Among those with a previous CABG, female gender and chronic kidney disease stage ≥3 were independently associated with a higher in-hospital mortality, whereas obesity was associated with a lower in-hospital mortality. In conclusion, there was a decrease in the proportion of patients with a previous CABG among those who underwent TAVI. TAVI among those with a previous CABG was not associated with increased in-hospital adverse events or 90-day all-cause readmissions.

Plant Based Diet and Its Effect on Cardiovascular Disease

Cardiovascular disease remains the leading cause of death globally and here in the United States. Diet has a major impact on the pathogenesis of atherosclerosis and subsequent cardiovascular morbidity and mortality. An unhealthy diet is the most significant potential behavioral and modifiable risk factor for ischemic heart disease. Despite these established facts, dietary interventions are far less frequent than pharmaceutical and procedural interventions in the management of cardiovascular disease. The beneficial effects of a plant-based diet on cardiovascular morbidity and mortality have been demonstrated in a number of recent clinical studies. The significant findings of each study are discussed in this review article, highlighting the role of a healthy plant-based diet in improving cardiovascular outcomes. From a clinician's standpoint, the knowledge and understanding of the facts and data points from these recent clinical studies would ensure more effective patient counseling on the substantial benefits of dietary interventions.

Heart Failure With Stable Mildly-reduced Ejection Fraction: Prognosis and Predictors of Outcomes

Heart failure with mildly-reduced ejection fraction (HFmrEF) of 40%-49% is an under-recognized type of heart failure. The prognosis and predictors of outcomes of stable mildly-reduced ejection fraction (EF) of 1 year are unclear. This is a retrospective study. Included patients had stable left ventricular ejection fraction (LVEF) for at least 1 year (n = 609) and were classified into 3 groups based on LVEF. Clinical outcome measures were all-cause mortality, cardiac mortality, and HF hospitalization (HFH). In patients with stable HFmrEF of one year, the predictors of clinical outcomes and hospital length of stay (LOS) were studied. Patients with stable HFmrEF had lower HFH rate compared to stable HFrEF with HR = 0.52 (95% CI = 0.39-0.70), P = 0.0001, and a higher HFH rate compared to stable HFpEF with HR = 1.23 (95% CI = 1.01-1.50), P = 0.032. Mortality rates were similar between all groups. In the stable HFmrEF patients, beta-blockers caused lower cardiac mortality, and CKD had fewer HFH. Unfavorable predictors were loop diuretics for mortality, and higher NYHA class for HFH. Smoking and CKD were associated with a longer hospital stay. Stable HFmrEF patients with at least one HF admission had higher mortality. Patients with stable HFmrEF had a lower HFH rate compared to stable HFrEF and higher HFH rate compared to stable HFpEF. In patients with stable HFmrEF, CKD, NYHA class, beta-blockers, and loop diuretics were predictors of clinical outcomes. Smoking and CKD were predictors of hospital LOS.

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients

In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.

Association of total and free testosterone with cardiovascular disease in a nationally representative sample of white, black, and Mexican American men

Associations of total testosterone (T) and calculated free T with cardiovascular disease (CVD) remain poorly understood. Particularly how these associations vary according to race and ethnicity in a nationally representative sample of men. Data included 7058 men (≥20 years) from NHANES. CVD was defined as any reported diagnosis of heart failure (HF), coronary artery disease (CAD), myocardial infarction (MI), and stroke. Total T (ng/mL) was obtained among males who participated in the morning examination. Weighted multivariable-adjusted logistic regression models were conducted. We found associations of low T (OR = 1.57, 95% CI = 1.17-2.11), low calculated free T (OR = 1.53, 95% CI = 1.10-2.17), total T (Q1 vs Q5), and calculated free T (Q1 vs Q5) with CVD after adjusting for estradiol and SHBG. In disease specific analysis, low T increased prevalence of MI (OR = 1.72, 95% CI = 1.08-2.75) and HF (OR = 1.74, 95% CI = 1.08-2.82), but a continuous increment of total T reduced the prevalence of CAD. Similar inverse associations were identified among White and Mexican Americans, but not Blacks (OR = 0.93, 95% CI = 0.49-1.76). Low levels of T and calculated free T were associated with an increased prevalence of overall CVD and among White and Mexican Americans. Associations remained in the same direction with specific CVD outcomes in the overall population.

Percutaneous Repair of Mitral Regurgitation: A Comprehensive Review of Literature

Mitral regurgitation is the most common valvular disease in the US and the second most common worldwide. Left untreated, it can lead to the development of heart failure, giving rise to increased mortality rates. Mitral valve intervention is usually indicated in severe mitral regurgitation at the onset of symptoms, even if the function of the left ventricle is preserved. A surgical approach is generally favored according to current guidelines, with excellent clinical outcomes. However, the emergence of novel data from contemporary trials indicates that percutaneous, catheter-based approach may have similar improvements in mortality outcomes while maintaining a superior safety profile when compared to the surgical approach. Here, we discuss transcatheter mitral valve repair as a treatment option for mitral regurgitation and summarize the major clinical trials which were recently conducted on transcatheter repair.

Accurate Estimation of Right-Filling Pressure Using Handheld Ultrasound Score in Patients with Heart Failure

INTRODUCTION

This study aims to evaluate the accuracy of bedside assessment of inferior vena cava (IVC) and right internal jugular (RIJ) vein in predicting right atrial (RA) pressure in heart failure patients.

METHODS

We prospectively studied 124 heart failure patients who were referred to our catheterization laboratory for right heart catheterizations to assess hemodynamics and to guide heart failure management. Just prior to the procedure, a handheld ultrasound examination was performed in each patient. The volume status was assessed by estimating RA pressure using end-expiratory IVC dimension, IVC respiratory collapsibility, and RIJ respiratory collapsibility. Patients were divided into 2 groups based on invasive RA pressure value. Multiple logistic regression models were used to identify factors associated with RA ≥10 mm Hg; a 3-point simple score was then created. The performance of this score was assessed using the receiver operating characteristics curve.

RESULTS

In this study 124 heart failure patients were included; median age was 59 years (interquartile range 48-65), and 40% were female. RIJ respiratory collapsibility <50%, end-expiratory IVC dimension ≥21 mm, and respiratory collapsibility <50% were significantly associated with elevated RA pressure, and were used to build the score. The area under the receiver operating characteristics curve (AUC) for the 3-point score was 0.84 (0.77-0.92), and it performed better than 2-point score using IVC characteristics alone (AUC 0.84 [0.77-0.92] vs 0.75 [0.67-0.83]; P = .003). Of 124 patients, 90 patients (72.5%) had concordant RA pressure and pulmonary capillary wedge pressure.

CONCLUSION

Concomitant ultrasound assessment of RIJ and IVC correlated better with RA pressure than IVC alone. A simple 3-point score can provide a useful and easily accessible tool to estimate volume status, and further guide management of heart failure patients.

Safety of Transcatheter Aortic Valve Replacement in Patients with Aortic Aneurysm: A Propensity-Matched Analysis

Introduction

There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA.

Methods

We queried the National Inpatient Sample database (2012–2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA.

Results

From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28–1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0–7.0) versus 3 days (IQR 2.0–6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73–1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81–1.69), p = 0.40], aortic dissection [OR 2.38 (0.41–13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18–1.16), p = 0.09], vascular complications [OR 0.80 (0.34–1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81–1.57), p = 0.42], blood transfusion [OR 1.20 (0.84–1.70), p = 0.26], and stroke [OR 0.58 (0.24–1.39), p = 0.25] were similar in those with and without AA.

Conclusions

Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-022-00258-6.

Age-specific trends and outcomes of hospitalizations with acute heart failure in the United States

OBJECTIVE

To analyze the age-specific temporal trends, in-hospital outcomes and readmissions for acute heart failure (HF).

BACKGROUND

There is a paucity of data on the age-specific differences in the trends and outcomes of hospitalizations with acute HF.

METHODS

The National Inpatients Sample database years 2002-2016 and the National Readmissions Database years 2013-2016 were used to identify primary hospitalizations for acute HF. We analyzed the age-specific temporal trends, in-hospital outcomes, and readmissions for acute HF.

RESULTS

The annual rate of hospitalizations for acute HF declined from 456 per 100,000 people in 2002 to 356 per 100,000 people in 2016 (P_trend < 0.001). The decline was observed among all age groups, except those aged 18-44 years. There was a decline in in-hospital mortality among all age groups, except for those aged 18-34 years. Compared with 18-34 years, adjusted in-hospital mortality was lower among 35-44 years (odds ratio 0.78, 95% confidence interval [CI] 0.74-0.82) and 45-54 years (OR 0.87; 95% CI 0.83-0.91) but higher among 55-64 years (OR 1.60; 95% CI 1.54-1.67) and ≥ 75 year (OR 2.54; 95% CI 2.44-2.64). Compared with 18-34 years, 30-day HF-related readmissions were significantly lower in older age groups (>34 years).

CONCLUSIONS

This nationwide contemporary analysis demonstrated a decline in the annual rates of hospitalizations with acute HF across all age categories except those aged 18-44 years. There was a reduction in rates of in-hospital mortality among middle-aged and older patients, but not in those aged 18-34. In-hospital mortality exhibited a dichotomous relationship with age. There was an inverse relationship between age and 30-days HF readmissions.

In-Hospital acute ischemic stroke following ST-elevation myocardial infarction

BACKGROUND

In-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States.

METHODS

We used 2003 to 2014 Nationwide Inpatient Sample data to identify adults with a principal diagnosis of STEMI. Patients were divided into two groups defined by presence or absence of ischemic stroke. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models identified factors associated with ischemic stroke, national trend of in-hospital stroke incidence and in-hospital mortality.

RESULTS

Of 1,842,529 STEMI patients hospitalized from 2003 to 2014, 22,268 (1.2%) developed acute in-hospital ischemic stroke. Those with acute strokes were older (age ≥ 65 years: 70% vs 46%), more likely female (51% vs 33%), and had higher rates of atrial fibrillation (28.9% vs 12.2%) and heart failure (40.5% vs 21.1%). Age and gender adjusted incidence of in-hospital ischemic stroke following STEMI remained stable; 1.4% in 2003 and 1.5% in 2014 (P trend = 0.50). However, age and gender adjusted in-hospital mortality declined in STEMI patients with and without in-hospital ischemic stroke [AOR 0.97 (0.95-0.99) P trend = 0.03, and AOR 0.98 (0.98-0.99) P trend < 0.001, respectively]. Patients with ischemic strokes had higher in-hospital mortality (25.7% Vs 7.2%, p < 0.001), [AOR 2.11, 95% CI (1.92-2.32)].

CONCLUSION

In the United States, the incidence of acute in-hospital stroke remained stable from 2003 to 2014 following STEMI with significant decrease of in-hospital mortality trends. Despite slight improvement in mortality trends, in-hospital mortality rates remained elevated calling for interventions to optimize health care delivery.

In-hospital left ventricular thrombus following ST-elevation myocardial infarction

BACKGROUND

In-hospital left ventricular (LV) thrombus following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale and was the focus of this investigation.

METHODS

We used the 2003 to 2013 Nationwide Inpatient Sample database to identify adults ≥18 years old with a principal diagnosis code of ST-elevation myocardial infarction. Patients were divided into two groups defined by the presence or absence of LV thrombus. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models were conducted to identify factors associated with LV thrombus.

RESULTS

Of 1,035,888 STEMI patients hospitalized in the U. S from 2003 to 2013, 1982 (0.2%) developed acute in-hospital LV thrombus. Compared to no LV thrombus, patients with LV thrombus were more likely to have in-hospital complications; acute ischemic and hemorrhagic stroke, acute renal failure, gastrointestinal bleed, cardiogenic shock, in-hospital cardiac arrest and mortality. They also had longer mean length of stay and higher hospital charges. Factors associated with LV thrombus included: anterior/anterolateral STEMI, acute or chronic heart failure with reduced ejection fraction, atrial fibrillation, LV aneurysm, Left heart valvular disease, acute or chronic deep venous thrombosis/pulmonary embolism and alcohol abuse. Patients with LV thrombus were less likely to be female [AOR 0.66, 95% CI (0.51-0.84)].

CONCLUSION

The identification of factors associated with early development of LV thrombus following STEMI, will help direct resources for specific high-risk group and prompt cost-effective therapies. Gender variability in LV thrombus development warrants further investigations.

Diarrhea-An uncommon presentation of tertiary adrenal insufficiency following heart transplantation

Diarrhea following organ transplantation is usually associated with infection and immunosuppression therapy. We describe two patients with diarrhea following orthotopic heart transplantation due to tertiary adrenal insufficiency.

Spontaneous Coronary Artery Dissection: One Disease, Variable Presentations, and Different Management Approaches

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females, typically in the absence of atherosclerotic coronary artery disease. Presentations vary greatly and this condition can be fatal. Given its rarity, there are no management guidelines. We present six patients with SCAD with different presentations and treatment approaches as examples in our literature review. Two patients presented with ST elevation myocardial infarction (STEMI), two with non-STEMI (NSTEMI), and two with cardiac arrest. Patients were treated according to the presentation, clinical stability, and extension and distribution of the dissection. Four patients underwent emergent percutaneous coronary intervention (PCI) and one was clinically stable and treated medically initially and underwent an elective PCI after 4 weeks when coronary angiogram showed persistent dissection. Another patient was treated medically as he was hemodynamically stable and the dissection affected a small branch. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used for diagnosis confirmation as well as during and after PCI to assure good stent apposition. All patients had excellent outcome. SCAD is a rare cause of acute coronary syndrome and a high index of suspicion is crucial for early diagnosis. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with PCI has excellent outcome. However, in stable patients, medical management and elective PCI in few weeks if the dissection persists is a more reasonable approach. IVUS and OCT are invaluable especially in ambiguous cases.

Influence of Access, Anticoagulant, and Bleeding Definition on Outcomes of Primary Percutaneous Coronary Intervention: Early Experience of an US Academic Center

Background We aimed to carry out comparison of different bleeding avoidance strategies in doing primary percutaneous coronary intervention (PPCI) using either radial or femoral as access of choice and either bivalirudin or unfractionated heparin as anticoagulant of choice. In this analysis, we analyzed the influence of major bleeding definition on bleeding outcomes as well. Methods We did a retrospective analysis of 139 patients with ST-segment elevation myocardial infarction (STEMI) who had PPCI in our academic center from January 2010 till October 2013. The primary outcome at 30 days was a composite of death from any cause or stent thrombosis or non-coronary artery bypass grafting (CABG) related major bleeding (CathPCI Registry definition) and secondary outcomes were individual components of primary outcome and the hospital length of stay. Results There was no significant difference among different access/anticoagulant combinations with regards to primary outcome (22% in radial/bivalirudin vs. 5% in radial/heparin vs. 17% in femoral/bivalirudin vs. 28% in femoral/heparin group; p = 0.2) as well as its individual components except the hospital length of stay (2.56 vs. 3 vs. 3.97 vs. 4.4 days each; p < 0.0001). The overall rate of major bleeding was 11.5%. When we use HORIZON-AMI bleeding definition, it went up to 25 % due to one particular component (p < 0.004). Conclusions This single center observational study doing PPCI did not show any superiority of one bleeding avoidance strategy over others with regard to primary outcome and its individual components except the hospital length of stay. It also shows the importance of bleeding definition on bleeding outcomes.

Park's stitch for a bicuspid aortic valve in a patient on LVAD support

A central coaptation stitch (Park's stitch) is a simple surgical option in the management of aortic insufficiency in patients with left ventricular assist devices. We describe a 66-year-old male with aortic insufficiency and a bicuspid aortic valve undergoing left ventricular assist device implantation. His aortic insufficiency was successfully addressed with a Park's stitch.

Acute heart transplant graft failure in association with hyperosmolar hyperglycemia state

We report a 38-year-old male with end-stage ischemic cardiomyopathy requiring left ventricular assist device placement, followed by orthotopic heart transplantation, who presented 18 months post-orthotopic heart transplant with acute graft failure with estimated left ventricular ejection fraction of 5% to 10%, in association with a glucose level of 550 mg/dL, and hemoglobin A1C of 13.8% and a negative pathology for a graft cellular and humoral rejection and no vasculaopthy. His left ventricular ejection fraction improved significantly to 40% to 45% within three days of optimal glucose control.

Reduced coronary blood flow in cardiac tamponade: mystery solved

A 67-year-old male presented with several week history of progressive shortness of breath, lower extremity edema, and distended jugular veins. Transthoracic echocardiography showed moderate pericardial effusion with thickened visceral pericardium and septal bounce but no chamber collapse. Right and left cardiac catheterization showed discordance of the right and left ventricular systolic pressures during respiration and severely reduced cardiac output. There was near equalization of diastolic pressures in all four chambers suggestive of effusive-constrictive pericarditis with cardiac tamponade physiology. Simultaneous coronary angiography showed remarkably reduced coronary Thrombolysis in Myocardial Infarction (TIMI) flow (TIMI grade 2 flow). Coronary blood flow was restored to normal after pericardial drainage on repeat coronary angiography. This is the first report of reduced coronary blood flow on coronary angiography in patients with effusive-constrictive pericarditis and cardiac tamponade. Our finding complements the work of previous investigators as we show that elevated intrapericardial pressures in cardiac tamponade can reduce coronary blood flow. This is likely related to extrinsic epicardial coronary vessel compression and reduced perfusion pressures, which can lead to myocardial ischemia and eventually cardiogenic shock.

Congenital coronary artery fistula presenting later in life

A 53-year-old male presented to our tertiary medical center with complaints of dyspnea and exertional chest pain with mild left ventricular dysfunction and right ventricular enlargement on echocardiography. Cardiac catheterization showed a congenital right coronary artery fistula communicating with the right sided chambers. Using contrast enhanced multi-detector computed tomography scan, the fistula was clearly draining into the coronary sinus. We describe briefly the etiology of coronary artery fistula, its clinical presentation, and the common tests used to confirm diagnosis. We further discuss the types of treatment modalities that are currently available.

Heart Disease in Patients with HIV/AIDS-An Emerging Clinical Problem

HIV/AIDS (Human immunodeficiency virus/ Acquired immuno deficiency syndrome) is a growing global problem, in terms of its incidence and mortality. Patients with HIV/AIDS are living much longer with HAART (Highly active antiretroviral therapy) therapy so much so that HIV/AIDS has now become a part of the chronic disease burden, like hypertension and diabetes. Patients with HIV/AIDS and symptoms suggestive of cardiac disease represent a diagnostic and therapeutic challenge in clinical practice; Cardiologists are more frequently encountering this problem. An algorithmic, anatomic approach to diagnosis, localizing disease to the endocardium, myocardium and pericardium can be useful. An intimate knowledge of opportunistic infections affecting the heart, effects of HAART therapy and therapy for opportunistic infections on the heart is needed to be able to formulate a differential diagnosis. Effects of HAART therapy, especially protease inhibitors on lipid and glucose metabolism, and their influence on progression to premature vascular disease require consideration. Treatment of cardiac disease, in HIV/AIDS patients can vary from non-HIV patients, based on drug interactions, differences in responsiveness, and other factors; and this area requires further research.

Dilated cardiomyopathy and myocardial infarction secondary to congenital generalized lipodystrophy

Congenital generalized lipodystrophy, also known as Berardinelli-Seip syndrome, is a very rare hereditary syndrome that is characterized by an almost complete absence of adipose tissue from birth. Cardiac involvement seems to have substantial influence in the long-term prognosis. Herein, we report an apparently unique case of congenital generalized lipodystrophy with cardiac sequelae. A 17-year-old woman, diagnosed in childhood with Berardinelli-Seip syndrome, presented with severe epigastric pain that was secondary to previous myocardial infarction. The patient had ischemia, dilated cardiomyopathy, and congestive heart failure, but no coronary artery disease. She was discharged from the hospital in stable condition after 3 days of medical treatment. To our knowledge, this is the 1st reported case of congenital generalized lipodystrophy with dilated cardiomyopathy, congestive heart failure, severe mitral regurgitation, and inferior myocardial infarction as cardiac sequelae of this syndrome--but without evidence of coronary artery disease or cardiac hypertrophy. In addition to discussing this patient's case, we present diagnostic and therapeutic approaches to Berardinelli-Seip syndrome.

Sirolimus-induced Alveolar Hemorrhage

Sirolimus is a well-known, potent immunosuppressant that is widely used in solid-organ transplantation, but it is not without potential side effects. A rare but devastating adverse effect is sirolimus-associated pulmonary toxicity. We report a case of sirolimus-induced diffuse alveolar hemorrhage confirmed by bronchoscopic findings (after other possible etiologies were ruled out) and by clinical and radiographic resolution of the pulmonary signs and symptoms a few days after sirolimus administration was stopped. This case and the existing literature on this topic suggest that sirolimus-induced pulmonary toxicity should be suspected in any patient taking immunosuppressants and who develops unexplained pulmonary symptoms.

The TandemHeart pVAD in the treatment of acute fulminant myocarditis

Acute fulminant myocarditis commonly manifests itself as severe, rapidly progressive hemodynamic deterioration and circulatory collapse that may be resistant to high doses of inotropic agents and steroids and to mechanical support by intra-aortic balloon pump. Acute myocarditis has a high mortality rate and may necessitate heart transplantation. The best short-term therapy available to support the patient may be a percutaneous left ventricular assist device. One such unit, the TandemHeart percutaneous ventricular assist device, can enable patients to recover in a few days. Two of our patients who experienced profound, therapy-resistant heart failure arising from acute myocarditis were successfully supported by the TandemHeart. To the best of our knowledge, these are the 1st reported cases in which the TandemHeart percutaneous ventricular assist device served as a bridge to recovery from acute fulminant myocarditis.

Impending cardiac tamponade as a primary presentation of hypothyroidism: case report and review of literature

OBJECTIVE

To describe a patient who presented with pericardial effusion and impending cardiac tamponade attributable to hypothyroidism.

METHODS

We present clinical, laboratory, and imaging data for the current patient and review the literature relative to clinical presentation, prevalence, pathophysiology, diagnosis, and treatment of pericardial effusion and tamponade.

RESULTS

In comparison with previously reported cases, our current case is rare, in that our patient, a 51-year-old woman, presented with impending cardiac tamponade as an initial manifestation of hypothyroidism. Echocardiography demonstrated a large pericardial effusion and diastolic right atrial collapse. A pericardial window procedure was performed, and 1,500 mL of fluid was removed. Levothyroxine therapy was initiated. One month later, recurrent pericardial effusion necessitated a similar intervention, after which the patient recovered and was managed by outpatient follow-up and monitoring of the thyrotropin level.

CONCLUSION

From our review of the literature, we conclude that impending cardiac tamponade is a rare initial manifestation of hypothyroidism. A high index of suspicion must be maintained for timely diagnosis of pericardial tamponade followed by prompt intervention. Recurrent pericardial effusions are common, necessitating close follow-up. Treatment of the hypothyroidism with levothyroxine is imperative.

Treatment of subclinical hypothyroidism reverses ischemia and prevents myocyte loss and progressive LV dysfunction in hamsters with dilated cardiomyopathy

Growing evidence suggests that thyroid dysfunction may contribute to progression of cardiac disease to heart failure. We investigated the effects of a therapeutic dose of thyroid hormones (TH) on cardiomyopathic (CM) hamsters from 4 to 6 mo of age. CM hamsters had subclinical hypothyroidism (normal thyroxine, elevated TSH). Left ventricular (LV) function was determined by echocardiography and hemodynamics. Whole tissue pathology and isolated myocyte size and number were assessed. TH treatment prevented the decline in heart rate and rate of LV pressure increase and improved LV ejection fraction. The percentage of fibrosis/necrosis in untreated 4-mo-old CM (4CM; 15.5 ± 2.2%) and 6-mo-old CM (6CM; 21.5 ± 2.4%) hamsters was pronounced and was reversed in treated CM (TCM; 11.9 ± 0.9%) hamsters. Total ventricular myocyte number was the same between 4- and 6-mo-old controls but was reduced by 30% in 4CM and 43% in 6CM hamsters. TH treatment completely prevented further loss of myocytes in TCM hamsters. Compared with age-matched controls, resting and maximum coronary blood flow was impaired in 4CM and 6CM hamsters. Blood flow was completely normalized by TH treatment. We conclude that TH treatment of CM hamsters with subclinical hypothyroidism normalized impaired coronary blood flow, which prevented the decline in LV function and loss of myocytes.

Pulmonary lymphangioleiomyomatosis in a postmenopausal woman: case report with review of literature

Lymphangioleiomyomatosis (LAM) is a rare disorder that occurs almost exclusively in young females and characterized by peribronchial, perivascular, and perilymphatic non-neoplastic proliferation of smooth-muscle cells. These changes may precipitate chylous effusions, pulmonary hemorrhage, bronchial cyst formation, progressive loss of lung function, and ultimately death. Most patients die within eight to ten years of the time of diagnosis. We report a rare case ofpost-menopausal onset pulmonary lymphangioleiomyomatosis in a 62-year old Caucasian female that was diagnosed at age 53 and responded well to intramuscular injections of Depo-Provera and bilateral oophorectomy. No symptom progression or pulmonary function test deterioration was noted over an eight year period of clinical follow-up. Our case is unique because of the postmenopausal onset and the unusual clinical course of the disease.