Lactococcus endocarditis after Bentall procedure presenting with intracranial hemorrhage

Background

Endocarditis is more common in patients with cardiac prostheses. A Bentall procedure entails surgical replacement of the aortic valve, aortic root, and ascending aorta with re-implantation of coronary arteries into the graft.

Case

65-year-old male with history of atrial fibrillation on rivaroxaban, bicuspid aortic valve, and ascending aortic aneurysm with a history of a Bentall procedure two years prior, presented with headache and dysarthria for one day. National Institutes of Health Stroke Scale was 3 and CT head showed 2.7 cm left frontal hematoma with extension into the subarachnoid space. Andexanet alfa was given for rivaroxaban reversal followed by cerebral angiogram which showed 5 mm intracranial inferior MCA aneurysm and embolization and coil placement was done. Blood cultures grew Lactococcus garvieae and transesophageal echocardiogram revealed aortic valve thickening and vegetation on the non-coronary cusp. He was subsequently treated with six weeks of IV ceftriaxone and Gentamycin.

Conclusion

With increasing use of bioprosthetic valves, the possibility of infective endocarditis with uncommon pathogens should be kept in mind. Lactococcus commonly affects native valves, however it can affect bioprosthetic valves and can present with mycotic aneurysms.

A Rare Case of High-Grade Atrioventricular Block in Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis (GPA) is an autoimmune disease that affects small and medium-sized vessels. It is classically known to present with renal and respiratory tract symptoms. However, the disease can manifest in other organ systems, especially cardiovascular involvement. Though there are multiple reports of cardiac involvement in GPA, it is not commonly evaluated and is often overlooked in patients with GPA. Heart disease in GPA has a wide range of presentations ranging from subacute and silent to severe abnormalities, which can prove fatal if not identified and treated appropriately. Identifying cardiac involvement early in patients with no apparent signs can help with prevention strategies and follow-up to avoid significant complications. Pericarditis is the most common pathology noted in GPA, followed by cardiomyopathy, coronary artery disease, valvular disease, and conduction abnormality. In our report, we present a case of GPA in a young male with asymptomatic conduction abnormality of the heart. Although it was silent at the presentation, identifying the initial electrocardiogram (ECG) changes prompted us to admit him to the telemetry floor. Continuous telemetry monitoring helped us identify the progression of the conduction abnormality, which otherwise could have been missed. This led us to correlate to his symptoms which he later developed during his admission course. His symptoms subsided after prompt treatment. If not identified early, these cardiac abnormalities can delay management, leading to increased disease burden and morbidity. Hence, essential cardiac work with at least ECG and continuous telemetry monitoring is recommended.

A Case of Peripartum Spontaneous Coronary Artery Dissection in a Woman With a History of Obesity

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) with a high prevalence in young pregnant females. A 38-year-old female with a history of morbid obesity status post-bariatric surgery presented with chest pain. The electrocardiogram (EKG) revealed ST-segment elevation in the inferior leads as well as slightly elevated troponin. Urgent cardiac catheterization showed SCAD, and she was subsequently managed with medical therapy. We hypothesize that the history of obesity leads to a compromise in the coronary vasculature, thereby predisposing the patient to SCAD.

Intra-Atrial Right Coronary Artery and Anomalous Origin of Left Circumflex Artery Found Concurrently

Coronary artery anomalies (CAAs) are known to be anatomical aberrations in the origin and structure. Due to the diverse anatomical variants, surgeons and angiographers have struggled when faced with patients who have CAA. To frame the complicated issues surrounding CAA, we present a case of a young patient found to have two CAAs, concurrently on coronary computed tomography angiography (CCTA), while in the emergency room being evaluated for chest pain. Patient was medically observed without any invasive procedure since he was deemed to have low cardiovascular risk. Subsequently, literature on prevalence, as well as high risk findings are reviewed. Further studies to evaluate pharmacological, angiographic, and surgical interventions may have additional benefit for both patients and practitioners. Our aim is to help shed the light on difficulties cardiologists are facing during angiography. Additionally, our paper offers some guidance for how to evaluate and follow patients with similar findings into the future.

The Association of Digital Health Application Use with Heart Failure Care and Outcomes: Insights from CONNECT-HF

BACKGROUND

It is unknown if digital applications may improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

CONNECT-HF included an optional, prospective ancillary study of a mobile health application among hospitalized patients for HFrEF. Digital users were matched to nonusers from the usual care group. Co-primary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2,431 patients offered digital applications across the United States, 1,526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs. 60 years, p=0.031). Digital users (N=368) versus matched nonusers (N=368) had improved composite HF quality scores (48.0% vs. 43.6%; +4.76% [3.27-6.24]; p=0.001) and composite clinical outcomes (33.0% vs. 39.6%; HR 0.76 [0.59-0.97]; p=0.027).

CONCLUSIONS

Among participants in CONNECT-HF, use of digital applications was modest, yet associated with higher HF quality of care scores, including use of GDMT, and better clinical outcomes. While cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.

Current Practice of Percutaneous Coronary Intervention in Patients With Coagulation Disorders

Acute coronary artery disease represents the leading cause of death worldwide. Some studies have shown that coagulation disorders can play a protective role against ischemic heart disease, presumably due to hypocoagulable state and decrease thrombin formation. However, autopsy reports showed atherosclerotic lesions in some patients with hemophilia. Since the introduction of clotting factors and replacement therapies, the life expectancy of patients with coagulation disorders has increased significantly. As a result, the incidence of cardiovascular diseases became higher making their treatment more challenging. Door to balloon strategy applies in ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention should not be delayed. While in non-STEMI (NSTEMI) and unstable angina, a hematology consult is essential. Prophylactic coagulation factor replacement is crucial in these patients in order to avoid bleeding complications, but on the other hand, these factors were also associated with thrombotic complications. Historically, bare-metal stents were preferred over drug-eluting stents in view of the shorter duration of dual antiplatelets therapy (DAPT). Currently, some trials have demonstrated the safety of new-generation drug-eluting stents in patients with elevated bleeding risk, where DAPT use is limited to four weeks. The radial artery is the preferred access and was found to have less bleeding complications when compared to the femoral access. Anticoagulation with heparin is the safest in view of antidote availability and shorter half-life. Bivalirudin has also been used in some case reports, while GP2b3a inhibitors are usually avoided except in a high thrombus burden. Close peri procedural follow-up is important with patient education about symptoms of bleed. Carefully and individually tailored antithrombotic and factor replacement therapy is required to overcome these clinically challenging situations. Early screening for cardiovascular risk factors and considering early intervention and management might help to improve the general health status of this population and reduce morbidity.

Purulent Pericarditis Caused by Bacteroides fragilis: A Rare Complication of Cholangitis

Bacterial infection is a rare cause of pericarditis especially in the post-antibiotic era. When compared to viral or idiopathic etiologies, purulent pericarditis carries a higher risk for complications. While most cases are due to Staphylococcus aureus, we present a rare case of pericarditis due to Bacteroides fragilis originating from a liver abscess and leading to pericardial effusion. Our case highlights the need to maintain a high clinical suspicion of bacterial infection when patients present with sepsis and have evidence of pericarditis.

Coronary Artery Diffuse Aneurysmal Dilation in an Acute Myocardial Infarction Patient

Coronary artery aneurysm (CAA) is a rare disease that is associated with dangerous dormant complications. It is associated with atherosclerotic heart disease in half of the cases during a coronary angiogram. Currently, there are no guidelines for the management of such cases. We present a case of acute ST-segment elevation myocardial infarction in a male patient who was found to have diffuse aneurysmal dilation of the coronary arteries along with 100% occlusion of the right coronary artery. The complexity of the lesions caused him not to be a candidate for either percutaneous or surgical intervention. This raises an important question regarding treatment options in such a rare case.

Cardiogenic Shock Secondary to Takotsubo Cardiomyopathy in a Patient with Preexisting Hypertrophic Obstructive Cardiomyopathy

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Echocardiography is used to diagnose hypertrophic obstructive cardiomyopathy (HOCM) and Takotsubo cardiomyopathy (TCM).

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Hypotension in a patient with TCM should be evaluated for left ventricular outflow tract obstruction (LVOTO).

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Management of TCM is challenging in patients with HOCM with severe LVOTO.

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Hypotension in LVOTO may paradoxically worsen with standard intravenous inotropes.

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Fluid resuscitation, beta-blockers, alpha agonists, and intra-aortic balloon pump are the treatment options in LVOTO.

Takotsubo Cardiomyopathy precipitated by opiate withdrawal

INTRODUCTION

Takotsubo Cardiomyopathy is a transient non-ischemic cardiomyopathy usually characterized by apical ballooning of the left ventricle, with electrocardiographic changes and enzyme release, without evidence of obstructive coronary artery disease. Typically seen in stress induced situations, in post-menopausal females, this condition may have a predilection for patients with dependency disorders.

CASE

The following is a case in which Takotsubo Cardiomyopathy was induced by withdrawal from opiate medications. Followed by resolution of symptoms after restarting maintenance opioid therapy.

DISCUSSION

We feel health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology. Given the prevalence of opiate use both recreational and iatrogenic, the index of suspicion for opiate-withdrawal induced cardiomyopathy should be high in the presence of cardiac symptomatology.

Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight

INTRODUCTION

Impella is a catheter-based micro-axial flow pump placed across the aortic valve, and it is currently the only percutaneous left ventricular assist device approved for high-risk percutaneous coronary intervention and cardiogenic shock. Areas Covered: Even though several studies have repeatedly demonstrated the excellent hemodynamic profile of Impella in high-risk settings, it remains underutilized. Here we aim to provide an up-to-date summary of the available literature on Impellas use in High risk settings as well as the practical aspects of its usage. Expert Commentary: Percutaneous coronary interventions in high rsk settings have always been challenging for a physician. Impella 2.5 and CP, have been proven safe, cost effective and feasible in High Risk Percutaneous coronary Interventions with an excellent hemodynamic profile.

Serum lipoprotein levels in takotsubo cardiomyopathy vs. myocardial infarction

Background

In the setting of myocardial infarction (MI) or acute coronary syndrome (ACS), current guidelines recommend early and aggressive lipid lowering therapy with statins, irrespective of the baseline lipoprotein levels. Takotsubo cardiomyopathy (TCM) patients have a clinical presentation similar to myocardial infarction and thus receive early and aggressive statin therapy during their initial hospitalization. However, the pathology of TCM is not atherosclerotic coronary artery disease and hence we assumed the lipid profiles in TCM would be healthier than coronary artery disease patients.

Methods

In this retrospective study, we assessed fasting serum lipoprotein levels of ten TCM patients and compared them with forty, age and sex-matched myocardial infarction (MI) patients.

Results

Comparing serum lipoprotein levels of TCM with MI group, there was no significant difference in mean total cholesterol between the two groups (174.5 mg/dL vs. 197.6 mg/dL, p = 0.12). However, in the TCM group, mean HDL-C was significantly higher (66.87 mg/dL vs. 36.5 mg/dL, p = 0.008), the mean LDL-C was significantly lower (89.7 mg/dL vs. 128.9 mg/dL, p = 0.0002), and mean triglycerides was also significantly lower (65.2 mg/dL vs. 166.8 mg/dL, p < 0.0001).

Conclusions

In this study, TCM patients in comparison to MI patients had significantly higher levels of HDL-C, lower levels of LDL-C levels and triglycerides. The lipid profiles in TCM were consistent with the underlying pathology of non-atherosclerotic, non-obstructive coronary artery disease. As lipoproteins in most TCM patients were within the optimal range, we recommend an individual assessment of lipid profiles along with their coronary heart disease risk factors for considering long term lipid-lowering therapy. A finding of hyperalphalipoproteinemia or hypotriglyceridemia in 40% of TCM patients is novel but this association needs to be confirmed in future studies with larger sample sizes. These findings may provide clues in understanding the pathogenesis of takotsubo cardiomyopathy.

Complete recovery of ischemic cardiomyopathy from thrombotic thrombocytopenic purpura

A 50 year old male HIV patient on antiretroviral therapy was admitted for chest pain. Upon admission, the patient was found to have elevated cardiac enzymes, acute thrombocytopenia, hemolytic anemia, acute pancreatitis and acute renal failure. The patient was diagnosed with thrombotic thrombocytopenic purpura/haemolytic uremic syndrome and emergency plasma exchange therapy was initiated along with aspirin, beta-blockers, steroids, and antiretroviral therapy. Patient responded well and demonstrated complete resolution of ischemic cardiomyopathy with left ventricular ejection fraction improving from 35% to 55% by the time of discharge. Essentially, prompt diagnosis and treatment can reverse cardiac damage induced by thrombotic thrombocytopenic purpura.

Unusual Cardiac Complications of Staphylococcus aureus Endocarditis

Bacterial endocarditis is a complex disease that is associated with significant morbidity and mortality. Staphylococcus aureus is an organism commonly responsible for acute bacterial infective endocarditis. Patients many times develop an acute fulminant infection resulting in multiple complications, even in the face of adequate therapy. We report an unusual case of S. aureus acute bacterial infective endocarditis in an immunocompromised patient resulting in multiple cardiac complications, including bacterial pericarditis with effusion, mycotic aneurysm of one of the coronary arteries, a valvular vegetation leading to an aneurysmal dilatation at the mitral-aortic junction (intervalvular fibrosa), and a fistulous communication between the left ventricle and left atrium. We present detailed echocardiographic images of these anomalies, which were subsequently confirmed intraoperatively. The patient underwent open heart surgery with pericardial patch repair of the mitral-aortic intervalvular fibrosa aneurysm and fistula.

Personal orientations and their relation to psychological and physiological symptoms of strain

Psychological and physiological symptoms of strain are investigated with consideration of five personal orientations hypothesized to be causally related to health and illness: self-image, locus of control, interpersonal orientation, goal orientation, and time orientation. The Stress Processing Report, an instrument designed to measure dysfunctional thinking styles, was administered to 816 individuals who also provided self-report data on psychological and physiological symptoms of strain. Clusters of symptoms were identified empirically and regressed on the personal orientations, controlling for the age and income of respondents. The five personal orientations were directly and, to some extent, differentially related to the clusters of symptoms. These findings, along with those of other recent studies, underscore the importance of considering the direct effects of individual characteristics in research on stress.