The Outcome of Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension during the COVID-19 Pandemic.

BACKGROUND: The coronavirus 2019 (COVID-19) has affected the lives of many people worldwide. Patients with chronic underlying morbidities are vulnerable to get the severe form of the infection. The goal of this study was to evaluate the outcome of patients with pulmonary arterial hypertension during the COVID-19 pandemic in Iran. METHODS: This cross-sectional study was conducted at a large tertiary center for pulmonary artery hypertension (PAH) patients. The primary end point was the prevalence of SARS-CoV-2 infection in PAH patients. The secondary end points were investigating the severity and mortality of COVID-19 infection in PAH patients during the COVID-19 pandemic. RESULTS: Totally 75 patients were enrolled in the study from December 2019 to October 2021 and 64% were female. The mean ± SD age was 49 ± 16 years. The prevalence of COVID-19 in PAH/chronic thromboembolic pulmonary hypertension patients was 44%. About 66.7% of patients had comorbidities, which was a prognostic factor for COVID-19 infection in PAH patients (P < 0.001). Fifty-six percent of infected patients were asymptomatic. The most reported symptoms in symptomatic patients were fever (28%) and malaise (29%). Twelve percent of patients were admitted with severe symptoms. The mortality rate in infected individuals was 3.7%. CONCLUSIONS: COVID-19 infection in PAH/chronic thromboembolic pulmonary hypertension patients seems to be associated with high mortality and morbidity. More scientific proof is needed to clarify different aspect of COVID-19 infection in this population.

Fatal Large Intracardiac in Situ Thrombus in a Mildly Symptomatic COVID-19 Patient: A Case Report.

Background: The coronavirus disease 2019 (COVID-19) has caused a global pandemic with a significant negative impact on health worldwide. Although it primarily involves the respiratory tract system, cardiovascular complications, particularly thrombotic events are increasingly reported and are associated with adverse outcomes. Case Summary: We describe a 30-year-old male who presented with exaggerated dyspnea and hypoxia with mild constitutional symptoms along with a positive PCR test for SARS-CoV-2. He was a known case of bronchiectasis and large bullae in the left lung. Transthoracic echocardiography showed a large right ventricle (RV) mass entrapped within RV papillary muscles and apex. Cardiac MRI was suggestive of RV thrombosis. Regarding diffuse underlying lung disease and improving respiratory symptoms with COVID-19 negative PCR test, we decided to prescribe anticoagulation with heparin infusion and then oral anticoagulant with Rivaroxaban 20 mg daily and follow up after 30 days. Unfortunately, the patient died after 2 weeks in his hometown. Conclusion: Thrombotic complications are frequently encountered in COVID-19 patients. We report a fatal case of large intracardiac thrombus associated with SARS-CoV-2 infection managed with anticoagulant therapy with a catastrophic outcome.

Remdesivir associated sinus bradycardia in patients with COVID-19: A prospective longitudinal study.

Background: Remdesivir is effective against SARS-Cov-2 with little evidence of its adverse effect on the cardiac system. The aim of the present study is investigating the incidence of bradycardia in COVID-19 patients treated with Remdesivir. Methods: This prospective longitudinal study was conducted in a tertiary center on COVID-19 patients for Remdesivir therapy. The objectives were to investigate the incidence of sinus bradycardia, and also the association between their demographics, underlying diseases, and the disease severity with developing bradycardia in COVID-19 patients treated with Remdesivir. Results: Of 177 patients, 44% were male. The mean (±standard deviation) age of patients was 49.79 ± 15.16 years old. Also, 33% were hospitalized due to more severe symptoms. Oxygen support was required for all hospitalized subjects. A total of 40% of the patients had comorbidities, with the most common comorbidity being hypertension. The overall incidence of bradycardia (heart rate<60 bpm) in patients receiving Remdesivir was 27%, of whom 70% had extreme bradycardia (heart rate <50 bpm). There was also a statistically significant reduction in heart rate after five doses of Remdesivir compared to the baseline heart rates. In the multivariable model, none of the covariates including age above 60 years, female sex, CRP>50 mg/L, O2 saturation<90%, underlying cardiovascular disease, hypertension and diabetes mellitus, and beta-blockers were associated with Remdesivir-induced bradycardia. No association was found between the COVID-19 severity indicators and bradycardia. Conclusion: As sinus bradycardia is a prevalent adverse cardiac effect of Remdesivir, it is recommended that all COVID-19 patients receiving Remdesivir, be evaluated for heart rate based on examination; and in the case of bradyarrhythmia, cardiac monitoring should be performed during administration to prevent adverse drug reactions.

Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients.

OBJECTIVES: Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. MATERIALS AND METHODS: Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. RESULTS: Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). CONCLUSIONS: Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.

Effect of COVID-19 medications on corrected QT interval and induction of torsade de pointes: Results of a multicenter national survey.

BACKGROUND: There are some data showing that repurposed drugs used for the Coronavirus disease-19 (COVID-19) have potential to increase the risk of QTc prolongation and torsade de pointes (TdP), and these arrhythmic side effects have not been adequately addressed in COVID-19 patients treated with these repurposed medications. METHODS: This is the prospective study of 2403 patients hospitalised at 13 hospitals within the COVID-19 epicentres of the Iran. These patients were treated with chloroquine, hydroxychloroquine, lopinavir/ritonavir, atazanavir/ritonavir, oseltamivir, favipiravir and remdesivir alone or in combination with azithromycin. The primary outcome of the study was incidence of critical QTc prolongation, and secondary outcomes were incidences of TdP and death. RESULTS: Of the 2403 patients, 2365 met inclusion criteria. The primary outcome of QTc ≥ 500 ms and ∆QTc ≥ 60 ms was observed in 11.2% and 17.6% of the patients, respectively. The secondary outcomes of TdP and death were reported in 0.38% and 9.8% of the patients, respectively. The risk of critical QT prolongation increased in the presence of female gender, history of heart failure, treatment with hydroxychloroquine, azithromycin combination therapy, simultaneous furosemide or beta-blocker therapy and acute renal or hepatic dysfunction. However, the risk of TdP was predicted by treatment with lopinavir-ritonavir, simultaneous amiodarone or furosemide administration and hypokalaemia during treatment. CONCLUSION: This cohort showed significant QTc prolongation with all COVID-19 medications studied, however, life-threatening arrhythmia of TdP occurred rarely. Among the repurposed drugs studied, hydroxychloroquine or lopinavir-ritonavir alone or in combination with azithromycin clearly demonstrated to increase the risk of critical QT prolongation and/or TdP.

Curable Syncope in Primary Pulmonary Hypertension with Novel Atrial Flow Regulator.

Pulmonary artery hypertension (PAH) occurs when mean pulmonary artery pressure (PAP) is higher than 25 mmHg in rest or 30 mmHg during activity. Idiopathic pulmonary artery hypertension (IPAH) is defined as PAH without a definite reason. The IPAH is a rare disease with a high mortality rate if left untreated. To date, there has been no definite cure for this entity, and most treatments are for symptom relief or improvement in the quality of life. For many years, decompressing the right heart through a hole in the interatrial septum has been advised to alleviate some of their symptoms, specifically syncope. Atrial flow regulator (AFR) is a device to make an iatrogenic interatrial hole and finally a unidirectional shunt. It has been used for some PAH patients for symptom relief. Herein, we report a 36-year-old female case with diagnosed IPAH for 6 years. In the last 3 years, the case had frequent syncope with shortening intervals. The AFR was implanted for her without any complications. Then, within 6 months of follow-up, she had only one syncope episode. A significant change was observed in her 6-minute walk and PAP.

Bronchial Angioembolization for Management of Hemoptysis Due to Pulmonary Tuberculosis.

BACKGROUND: The study aimed to evaluate the effectiveness and safety of BAE in TB patient with massive hemoptysis and evaluate the recurrence rate of hemoptysis after BAE. MATERIALS AND METHODS: In this prospective study, 68 patients with moderate and severe hemoptysis due to active or old tuberculosis who underwent bronchial arteriography were included. CXR and CT scan were performed in all patients. Selective and nonselective bronchial artery angiography was performed in all patient and 62 patients underwent embolization. RESULTS: Thirty-two patients (47.1%) had active TB and 36 patients (52.9%) had inactive TB (post-tuberculosis sequelae). Abnormality was detected in a single vessel in 30 (44.1%) patients, in two vessels in 23 (33.8%) and in more than two vessels in 13 (19.1%) patients. Embolization was performed in 62 patients and overall 95 abnormal arteries were embolized. Hemoptysis control rate was 82.3% at one month, 73.5% at three months, 69.1 % at 6 months, 63.2% at one year and 60.3% after two years. CONCLUSION: No major complication occurred as a result of BAE procedures. BAE is a safe and effective method for the management of hemoptysis in patient with tuberculosis. Only 20.6% of the patients need to repeat BAE during 2 years of follow up.

Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis.

BACKGROUND: Massive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter. METHODS: In this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up. RESULTS: 153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography. CONCLUSION: BAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.

A simple hemodynamic parameter to predict clinical worsening in pulmonary arterial hypertension.

BACKGROUND: Predicting prognosis is a cornerstone in management of pulmonary arterial hypertension. Hemodynamic parameters are among the robust indicators of right ventricular function and prognosis. In this study we have investigated the association of a simple hemodynamic parameter with clinical worsening in pulmonary arterial hypertension. METHODS AND PATIENTS: 120 patients were enrolled in a single center prospective cohort study after confirmation of precapillary pulmonary hypertension and were followed for an average of 36months on guideline recommended treatment protocols. cSvO2 was calculated as the ratio of right atrial pressure over Mixed Venous Oxygen Saturation. Independent predictors of clinical worsening were identified using multivariable Cox regression models. RESULTS: By the end of the follow up a total of 21 patients died and 63 were hospitalized for pulmonary hypertension. Time-to-event Cox regression model showed a strong association between cSvO2 and time to clinical worsening (HR: 250.13, CI: (38.56-1622.34) &p-value: <0.0001). CONCLUSION: The index of cSvO2 includes both parameters of cardiac output and right ventricular filling pressure and might be beneficial in predicting clinical worsening in patients with pulmonary arterial hypertension.