Coronavirus disease 2019 (COVID-19): Multisystem review of pathophysiology

Coronavirus disease-19 (COVID-19) pandemic is associated with high morbidity and mortality. COVID-19, which is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2), affects multiple organ systems through a myriad of mechanisms. Afflicted patients present with a vast constellation of symptoms, from asymptomatic disease to life-threatening complications. The most common manifestations pertain to mild pulmonary symptoms, which can progress to respiratory distress syndrome and venous thromboembolism. However, in patients with renal failure, life-threatening cardiac abnormalities can ensue. Various mechanisms such as viral entry through Angiotensin receptor (ACE) affecting multiple organs and thus releasing pro-inflammatory markers have been postulated. Nevertheless, the predictors of various presentations in the affected population remain elusive. An ameliorated understanding of the pathology and pathogenesis of the viral infection has led to the development of variable treatment options, with many more that are presently under trial. This review article discusses the pathogenesis of multiple organ involvement secondary to COVID-19 infection in infected patients.

•

This review sheds light on the pathogenesis of multi-organ involvement secondary to COVID-19 infection.

•

The predictors of various presentations in the affected population are not clear at present. A better understanding of the pathology and pathogenesis of the viral infection will be pivotal in the development of variable treatment options.

•

Various proposed mechanisms such as viral entry through Angiotensin receptor (ACE) affecting multiple organs, releasing pro-inflammatory markers and cytokines inducing hypercoagulable state and cytokine storm syndrome have been postulated.

Coronary intravascular lithotripsy for coronary artery calcifications- systematic review of cases

Background: Coronary artery calcification (CAC) is a pathological deposition of calcium in the intimal and medial layer of the arterial wall. A plethora of therapeutic calcium debulking techniques is available for the treatment of CAC, including orbital or rotational atherectomy, excimer lasers, cutting, and scoring balloons, which are associated with a soaring rate of complication and low efficacy. To this end, in 2016, the Food and Drug Administration (FDA) posited that shockwave intravascular lithotripsy (S-IVL) technique can be employed with minimal complication.

Methods: A retrospective review of cases received lithotripsy for calcified coronary artery disease was performed by using online data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The available search results were downloaded into an Endnote library and analyzed into two phases.

Results: Out of 24 participants from case reports and series, Majority were found to be Male. There was no significant difference found in the mortality of patients undergoing IVL for the stenosis of the left main stem, left anterior descending, left circumflex artery, or diagonal branch. The mortality was found to be high among 6 patients with prior comorbidities and underwent more than 3 cycles of IVL (OR 37,95% Cl 1.54–886.04, P 0.02). Out of 24 patients, 2 (8.33%) patients developed complications such as vessel dissection (OR 3.4, 95% Cl 17.87–64.68, P 0.4).

Conclusion: Shockwave intravascular lithotripsy (S-IVL) may be used in cases of the calcified disease to gain vessel lumen in order to deploy drug-eluting stents with PCI. The success of the DES implantation of IVL can be 100% with a minimal complication rate.

Complications of leadless vs conventional (lead) artificial pacemakers - a retrospective review

Background: Leadless pacemakers (LPM) are introduced in cardiovascular market with a goal to avoid lead- and pocket-associated complications due to conventional artificial pacemakers (CPM). The comparison of LPM and CPM complications is not well studied at a case by case level.

Methods: Comprehensive literature was searched on multiple databases performed from inception to December 2019 and revealed 204 cases that received LPM with a comparison of CPM. The data of complications were extracted, screened by independent authors and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY: IBM Corp.).

Results: The complications of CPM were high in comparison to LPM in terms of electrode dislodgement (56% vs 7% of cases, p-value < .0001), pocket site infection rate (16% vs 3.4%, p-value = 0.02), and a lead fracture rate (8% vs 0%, p-value = 0.04). LPMs had a statistically non-significant two-times high risk of pericardial effusion (8%) compared to CPMs (4%) with a p-value = 0.8.

Conclusion: LPMs appear to have a better safety profile than CPMs. There was a low pocket site and lead-related infections in LPM as compared to CPM. However, LPM can have twice the risk of pericardial effusion than CPMs, but this was not statistically significant.

COVID-19 cardiovascular epidemiology, cellular pathogenesis, clinical manifestations and management

Coronavirus Disease 2019 (COVID-19) is a rapidly progressing global pandemic that may present with a variety of cardiac manifestations including, but not limited to, myocardial injury, myocardial infarction, arrhythmias, heart failure, cardiomyopathy, shock, thromboembolism, and cardiac arrest. These cardiovascular effects are worse in patients who have pre-existing cardiac conditions such as coronary artery disease, hypertension, diabetes mellitus, and coagulation abnormalities. Other predisposing risk factors include advanced age, immunocompromised state, and underlying systemic inflammatory conditions. Here we review the cellular pathophysiology, clinical manifestations and treatment modalities of the cardiac manifestations seen in patients with COVID-19.

An unusual case of fungal ball on implantable cardioverter defibrillator wire and literature review

Cardiac Implantable Electronic Device (CIED) includes pacemakers and implantable cardioverter defibrillators (ICD). The device infection is classified into pocket and systemic infection. We present a case of candida fungemia secondary to dissemination from the fungal ball found on an ICD. Patient was successfully managed with IV fluconazole, ICD explantation and reimplantation. The purpose of this report is to highlight rare complications of ICD implantation and guide its clinical course and management.

Coronavirus Disease 2019 With Acute Respiratory Distress Syndrome Mimicking Heart Failure Exacerbation: Time to Rethink

A 67-year-old man with a prior heart failure presented with fever, cough and dyspnea for 4 days. Physical examination showed bilateral rales on the lung exam, yet no lower extremity edema. The combination of symptoms, elevated inflammatory markers, normal baseline pro-B-type natriuretic peptide, PaO2/FiO2 < 300 and positive swab suggested coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS) rather than heart failure exacerbation. We discuss the challenges in management of ARDS in COVID-19 patients that may initially mimic as acute exacerbation of heart failure.

Bradycardia, Renal Failure, Atrioventricular-nodal Blocker, Shock, and Hyperkalemia Syndrome Diagnosis and Literature Review

The combination of bradycardia, renal failure, atrioventricular (AV)-nodal blocker medications, shock, and hyperkalemia (BRASH) is a new syndrome that is a consequence of a positive loop of bradycardia due to AV-nodal blockers and hyperkalemia secondary to renal insufficiency. We present a case of BRASH syndrome in which the patient on chronic AV-nodal blockers presented with bradycardia, hypotension, underlying kidney dysfunction, and hyperkalemia. The patient was medically managed and discharged upon clinical improvement. The purpose of this report is to highlight the rare cases of BRASH syndrome and improve its management.

Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement: A Review of Aortic Stenosis Management

Severe aortic stenosis (AS) affects 3.4% of the elderly over 60 years of age. It presents with exertional dyspnea, syncope, angina, and progression to irreversible congestive heart failure. Early intervention produces a better outcome in preventing the clinical deterioration of AS. The choice of intervention is transcatheter aortic valve implantation or surgical aortic valve replacement (SAVR). The decision should be made after evaluating an individual case based on its clinical features and the user’s experience with transcatheter aortic valve replacement (TAVR). We reviewed available data to illustrate the types of ASs, the background of interventions, current guidelines for TAVR, and its comparison with SAVR in terms of adverse effects.

A Systematic Review of a Long-forgotten Cause of Atrial Fibrillation and Stroke: Cor Triatriatum

Cor triatriatum is a rare congenital cardiac condition characterized by the division of one atrium into two chambers by a fibromuscular membrane, resulting in three atrial chambers. The goal of this study was to determine the associations of cor triatriatum with cyanosis, atrial fibrillation (AF), and stroke.

MEDLINE (PubMed, Ovid), Embase, and Cochrane databases were searched on April 25, 2019, for relevant articles on cor triatriatum. After initial screening and removal of duplicates, 235 articles were selected. Data were extracted from these articles, including types, presentations, diagnostic findings, management, and outcomes of patients with cor triatriatum.

Approximately 83% of patients with cor triatriatum had cor triatriatum sinistrum (CTS) and 17% had cor triatriatum dextrum (CTD). The mean age of all patients was 29±23 years. Mean ages at diagnosis differed significantly in patients with CTS and CTD (31±23 years vs. 21±20 years, p=0.02). CTS showed a significantly greater association with AF (14.65% vs. 12.5%, p=0.036) and had a substantially higher risk of stroke (7.9% vs. 5.0%, p=0.04) than CTD. CTS also had a numerically higher association with atrial septal defects (15.13% vs. 15.6%), but this difference was not statistically significant (p=0.89). In contrast, cyanosis at presentation was significantly more frequent in patients with CTD than CTS (5.5% vs. 5.3%, p=0.05). Management did not differ significantly between these groups (p=0.29). The overall mortality rate was 16%, with no significant difference between patients with CTS and CTD (p=0.33).

The higher likelihood of AF and stroke in CTS than in CTD patients warrants treatment of the former with anticoagulation agents, irrespective of their CHA₂DS₂-VASc scores (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex category). Patients with CTS usually present at an older age due to their lower risk of cyanosis and asymptomatic AF.

Current efficacy of antibiotics against Klebsiella isolates from urine samples - a multi-centric experience in Karachi

Due to emergence of bacterial resistant strains, the effectiveness of current antibiotic treatment without culture/sensitivity testing is questionable. Our study aims to assess the present sensitivity profiles of Klebsiella isolates from urine samples and provide options for empiric prescription in critically ill patients. Klebsiella pneumoniae isolates collected over a period of 28 months till January 2011 from 1,617 urine samples of subjects presenting with Urinary Tract Infections were identified at a local diagnostic lab using standard protocol and subjected to Kirby-Bauer disk diffusion sensitivity testing. MICs were also estimated by E-nephelometry. Among 20 drugs used, low sensitivity was found to amoxicillin (0.1%), doxycycline (11.5%), nitrofurantoin (15.5%), amoxiclav (18.2%), gentamicin (35.4%), pipemidic acid, cephradine (40.3%) and cotrimoxazole (43.1%). The isolates were more sensitive to cefuroxime (55.9%), cefixime (57.7%), ciprofloxacin (62.5%), ofloxacin (63%), ceftriaxone (66.2%), ceftazidime (66.4%), cefotaxime (66.6%), fosfomycin (77.5%) and amikacin (89.4). Most effective were cefroperazone.sulbactam (95.8%), piperacillin.tazobactam (95.7%) and imipenem (97.7%). Self-medication, lack of awareness, and the misuse of antibiotics by doctors has exacerbated the menace of microbial resistance. The study warrants the prudent choice of drugs in adherence with prevailing sensitivity profiles.

Transition from a Tomonaga-Luttinger liquid to a fermi liquid in potassium-intercalated bundles of single-wall carbon nanotubes

We report on the first direct observation of a transition from a Tomonaga-Luttinger liquid to a Fermi-liquid behavior in potassium-intercalated mats of single-wall carbon nanotubes. Using high resolution photoemission spectroscopy, an analysis of the spectral shape near the Fermi level reveals a Tomonaga-Luttinger liquid power law scaling in the density of states for the pristine sample and for low dopant concentration. As soon as the doping is high enough to achieve a filling of the conduction bands of the semiconducting tubes, a distinct transition to metallic single-wall carbon nanotube bundles with the scaling behavior of a normal Fermi liquid occurs.