Plasminogen Activator Inhibitor-1 4G/5G Polymorphism Presenting as Recurrent Ischemic Stroke: The Microthrombi Shower.

Certain clinical scenarios should alert a physician to take a deeper look into causative pathological processes. This was evident in the case of a 41-year-old man who presented for recurrent micro thromboembolic strokes, which is atypical for the patient's age. Our desire to explain the pathological process led to the rare finding of a plasminogen activator inhibitor-1 polymorphism, which has been associated with an increased risk of cerebrovascular thrombosis. A defect in this pathway leads to the inhibition of the tissue plasminogen activator protein. This genetic polymorphism has relatively been unexplored in recent medical literature, and we are hoping that our case may inspire future research that could help potential targets of risk factor stratifications as well as the development of novel pharmacological options.

SARS-CoV-2 Viral Load and Myocardial Injury: Independent and Incremental Predictors of Adverse Outcome.

To evaluate the association of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) initial viral load (iVL) and the incidence of myocardial injury (MCI) in hospitalized patients with SARS-CoV-2 infection, we conducted a retrospective longitudinal study of hospitalized patients who had a nasopharyngeal swab sample on admission that returned a positive result for SARS-CoV-2 by polymerase chain reaction between April 4 and June 5, 2020. The cycle threshold (Ct) value was used as a surrogate for the iVL level, with a Ct level of 36 or less for elevated iVL and greater than 36 for low iVL. Myocardial injury was defined as an elevated high-sensitivity cardiac troponin I level that was higher than the 99th percentile upper reference limit. A total of 270 patients were included. Of these, 171 (63.3%) had an elevated iVL and 88 (32.6%) had MCI. There was no significant difference in the incidence of MCI in patients with low iVL compared to those with elevated iVL (28 of 99 [28.3%] vs 60 of 171 [35.1%]; P=.25). In a multivariable model, MCI (odds ratio, 3.86; 95% CI, 1.80 to 8.34; P<.001) and elevated iVL (odds ratio, 4.21; 95% CI, 2.06 to 8.61; P<.001) were independent and incremental predictors of in-hospital mortality. The SARS-CoV-2 iVL level is not associated with increased incidence of MCI, although both parameters are strong independent and incremental predictors of mortality. Understanding the MCI mechanisms allows for early focused interventions to improve survival, especially in patients with SARS-CoV-2 infection and high iVL.

Increasing Diversity in Cardiology: A Fellowship Director's Perspective.

Background Underrepresented-minorities (URM) remain few in number amongst practicing cardiologists and across cardiology fellowship training programs in the U.S. Increased diversity is needed across the entire field and is particularly necessary within graduate medical education cardiology fellowship training programs. Objectives This cross-sectional study was performed to identify which strategies were supported and implemented by cardiology fellowship program directors (PDs) to increase URM representation, to determine which entities hold the responsibility to increase diversity according to program directors, and to quantify URM representation in cardiology fellowship programs. Methods A 15-item survey was submitted to all American College of Graduate Medical Education (ACGME) accredited cardiology fellowship programs via electronic mail. Results Of 250 cardiology fellowship programs, 71 responses were received (28.4%). The number of URM faculty varied from 0-1 to more than six, and URM faculty held leadership roles in most programs (62.0%). A total of 16 respondents (22.5%) were URM program directors. Most respondents agreed that diversity was important to their training program (85.9%). The majority endorsed direct recruitment of URM applicants (60.6%), opportunities for applicants to connect with (54.9%) or be recruited by URM fellows (54.9%), holistic application review (67.6%), promoting mentorship by URM faculty (69.0%), URM faculty involvement in applicant interviewing (54.9%), and increased recruitment of URM faculty members (73.2%). Program directors allocated major responsibility to increase diversity to fellowship programs (71.8%), residency programs (63.3%), and medical schools (53.5%). Conclusions This study found that most cardiology programs have URM faculty in leadership roles, and nearly a quarter of the surveyed program directors were URMs. Cardiology program directors endorsed and employed numerous strategies to increase diversity and URM representation in fellowship programs. Additionally, program directors held fellowship training programs most responsible for increasing URM representation in the field of cardiology.

Esophago-Pericardial Fistulae as a Sequela of Boerhaave Syndrome and Esophageal Stenting: A Case Report and Review of Literature.

Esophago-pericardial fistulae is a rare and dreaded entity. Most reported cases in the literature were described in association with advanced upper gastrointestinal malignancies, prior surgical procedures, and radiofrequency atrial fibrillation ablation. It has been rarely reported in association with benign esophageal conditions. Surgery had been the mainstay of treatment, but there are increasingly reported cases treated successfully with esophageal stenting and pericardial drainage. In this article, we report a novel case of an esophago-pericardial fistulae occurring as a sequela of esophageal stent placed for the management of Boerhaave syndrome.

Methadone-Induced Polymorphic Ventricular Tachycardia Complicated by Takotsubo Cardiomyopathy in a Malnourished Patient.

Takotsubo cardiomyopathy (TC) is a syndrome characterized by acute and transient regional systolic myocardial dysfunction. TC often mimics myocardial infarction without obstructive coronary disease. We present a case of a 48-year-old woman who developed TC following the onset of polymorphic ventricular tachycardia in the setting of methadone intoxication.

Impact of Chronic Thrombocytopenia on Outcomes After Transcatheter Valvular Intervention and Cardiac Devices Implantation (From a National Inpatient Sample).

To evaluate the impact of chronic thrombocytopenia (cTCP) on outcomes of transcatheter valvular procedures such as aortic valve implantation (TAVI), MitraClip, permanent pacemaker (PPM), implantable-cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), left atrial appendage closure, and pericardiocentesis. Impact of cTCP on clinical outcomes following TAVI, Mitraclip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis procedures is not well described. Utilizing the National Inpatient Sample and (ICD-9-CM) procedural codes, we evaluated patients (age ≥18 years) who underwent these procedures, from January 1, 2009 to December 31, 2014, with or without cTCP as a chronic condition variable indicator. Propensity score matching model implemented to derive 2 matched groups. Propensity score matching created 47,292 and 47,351 hospitalizations matched pairs with and without cTCP, respectively. Patients with cTCP were older (mean age, 74.27 vs 72.26 years; absolute standardized differences [ASD] = 15.6) and less likely to be female (36.76% vs 43.74%, ASD = -14.31). They experienced higher in-hospital mortality (3.0% vs 2.0%; odds ratio [OR], 1.53; 95% confidence interval [CI], 1.27 to 1.83) and higher odds of vascular injury requiring surgery (2.63% vs 1.10%; OR, 2.43; 95% CI, 1.93 to 3.05). Postoperative hematoma and bleeding were 2-fold higher (4.57% vs 2.24%; OR, 2.08; 95% CI, 1.77 to 2.45) and 3-fold higher (6.34% vs 2.45%; OR, 2.69; 95% CI, 2.31 to 3.13) respectively among cTCP patients. They had greater health-care cost ($47,163 vs $35,763, p <0.0001) and longer hospital stay (mean 9.26 days vs 6.84 days, p <0.0001). In conclusion, cTCP patients had higher risk of complications after TAVI, MitraClip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis, including a 1.5-fold increased risk of in-hospital mortality.

Rare case of implantable cardioverter defibrillator infection caused by Stenotrophomonas maltophilia and Pantoea calida.

Despite the numerous advancements in cardiac implantable electronic defibrillator (CIED) designs and implantation techniques, device-related infections continue to represent significant morbidity and mortality. Although Gram-positive bacteria remain the most commonly reported organisms, various other bacterial families have been reported. We describe a 61-year-old patient with a history of non-ischaemic cardiomyopathy who presented with implantable cardioverter defibrillator pocket infection due to Stenotrophomonas maltophilia and Pantoea calida that developed a few days following the device generator replacement. Early device explantation, tissue sampling and initiation of sensitivity-directed antibiotics are necessary steps for early diagnosis and management of such CIED-related infections. S. maltophilia and P. calida should be added to the expanding list of the causative organisms behind CIED-related infections. Our case and available literature demonstrated excellent sensitivity of these two organisms to sulfamethoxazole-trimethoprim treatment.

Incidence and outcomes of cardiac tamponade in patients undergoing cardiac resynchronization therapy.

INTRODUCTION: Cardiac tamponade is a severe complication of cardiac resynchronization therapy (CRT) implantations. We provide a contemporary large-scale study evaluating the incident trends, predictors and impact of cardiac tamponade in patients undergoing CRT. METHOD: Data were obtained from the Nationwide Inpatient Sample (NIS) of 2007 through 2014. Trends in the annual rates of tamponades in CRT implantation were assessed using negative binomial regressions. Hierarchical mixed-effects logistic regression models were built to determine the independent predictors of tamponade in CRT implantation and 1:1 propensity-matched analysis performed to examine the impact of tamponade on outcomes. RESULT: An estimated 310,704 CRT implantations were performed in the United States between 2007 and 2014, out of which 536 patients (0.17%) developed procedure-related cardiac tamponade. A significant increasing trend in the tamponade incidence was observed over the 8-year study period [1.65 per 10,000 CRT implantation in 2007 to 38.16 in 2014 (p < 0.001)]. After multivariable adjustment, female sex and coagulation disorder were found to be independently associated with higher odds of tamponade. Conversely, prior history of CABG procedure was associated with lower odds of tamponade. CRT complicated with tamponade had significantly increased in-hospital mortality, bleeding requiring transfusion, prolonged hospital stay and increased cost. CONCLUSION: We found an increasing trend in the incidence of post CRT tamponade among hospitalized patients between 2007 and 2014. Female gender and coagulation disorder were associated with the development of tamponade among recipients of CRT. Risk stratification of patients who are undergoing CRT is crucial to improving outcome in CRT implantation.

Financial Implications and Impact of Pre-existing Atrial Fibrillation on In-Hospital Outcomes in Patients Who Underwent Transcatheter Aortic Valve Implantation (from the National Inpatient Database).

The objective of this study was to evaluate the financial implications and the impact of pre-existing atrial fibrillation (AF) on in-hospital outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) using the Nationwide Inpatient Sample (NIS) database. We identified patients who underwent TAVI from 2011 to 2014. The primary end point was the effect of pre-existing AF on in-hospital mortality. Secondary end points included periprocedural cardiac complications, stroke, and hemorrhage requiring transfusion. We also assessed length of stay (LOS) and cost of hospitalization. A mixed-effect logistic model was used for clinical end points, and a linear mixed model was used for cost and LOS. In 6,778 patients who underwent TAVI (46.1% women and 81.4 ± 8.5 years old), the incidence of AF was 43.3%. After adjusting for patient- and hospital-level characteristics, pre-existing AF was not found to influence in-hospital mortality (odds ratio 1.05, 95% confidence interval 0.80 to 1.36). AF was associated with an increased risk of periprocedural cardiac complications (odds ratio 1.46, 95% confidence interval 1.22 to 1.75), longer LOS (p <0.001) and an increased cost of hospitalization (US$51,852 vs US$49,599). In conclusion, pre-existing AF did not impact in-hospital mortality in TAVI patients but was associated with increased cardiac complications, a longer hospital LOS, and a higher cost of hospitalization.

Subacute Right Ventricular Perforation by Pacemaker Lead Causing Left-Sided Hemothorax and Epicardial Hematoma.

We report a case of right ventricular wall perforation by a pacemaker lead in a 78-year-old female 18 days after a permanent pacemaker insertion. This injury necessitated explant of the perforating lead and implantation of a new one with surgical backup. We review the literature and discuss the possible risk and protective factors including lead models that were associated with higher incidence of perforation. We review the traditional pacing parameters and their lack of reliability to diagnose perforation and the need for low threshold to utilize imaging in appropriate clinical scenarios. The authors believe this case is of educational value to all health care professionals, especially emergency medicine and internal medicine residents, who routinely see patients with pacemakers complaining of chest pain, shortness of breath, or dizziness.

Vagus Nerve Stimulation for the Treatment of Heart Failure: The INOVATE-HF Trial.

BACKGROUND: Heart failure (HF) is increasing in prevalence and is a major cause of morbidity and mortality despite advances in medical and device therapy. Autonomic imbalance, with excess sympathetic activation and decreased vagal tone, is an integral component of the pathophysiology of HF. OBJECTIVES: The INOVATE-HF (Increase of Vagal Tone in Heart Failure) trial assessed the safety and efficacy of vagal nerve stimulation (VNS) among patients with HF and a reduced ejection fraction. METHODS: INOVATE-HF was a multinational, randomized trial involving 85 centers including patients with chronic HF, New York Heart Association functional class III symptoms and ejection fraction ≤40%. Patients were assigned to device implantation to provide VNS (active) or continued medical therapy (control) in a 3:2 ratio. The primary efficacy endpoint was composite of death from any cause or first event for worsening HF. RESULTS: Patients (n = 707) were randomized and followed up for a mean of 16 months. The primary efficacy outcome occurred in 132 of 436 patients in the VNS group, compared to 70 of 271 in the control group (30.3% vs. 25.8%; hazard ratio: 1.14; 95% confidence interval: 0.86 to 1.53; p = 0.37). During the trial, the estimated annual mortality rates were 9.3% and 7.1%, respectively (p = 0.19). Quality of life, New York Heart Association functional class, and 6-min walking distance were favorably affected by VNS (p < 0.05), but left ventricular end-systolic volume index was not different (p = 0.49). CONCLUSIONS: VNS does not reduce the rate of death or HF events in chronic HF patients. (INcrease Of VAgal TonE in CHF [INOVATE-HF]; NCT01303718).

Low referral pattern for implantable defibrillator therapy in a tertiary hospital: referral physician survey and Monte Carlo simulation.

Although implantable cardioverter defibrillator (ICD) therapy is the standard of care for prevention of sudden cardiac death (SCD), its underutilization is a clinical concern. We performed a retrospective study on patients who underwent cardiac catheterization at a tertiary medical center to identify those who were eligible for ICD therapy as per the guidelines and those who actually received it as a part of treatment. Surprisingly, only 4.4% of eligible patients received ICD for SCD prevention. Assuming that the major cause of this underutilization of ICD therapy was low referral, we performed a structured survey among the referring physicians to assess specialists' availability, primary care physicians' role in ICD referral, patient management concerns, familiarity with ICD guidelines, and economics of ICD implantation. Physician response rate of the survey was 51% (35/68). Survey results showed that the common reasons for underreferral included nonavailability of electrophysiologists (34%), poor quality of life of patients (25.7%), patients not being on optimal therapy (25.7%), and low awareness (22.85%). Subsequently, a Monte Carlo simulation was used to assess a hypothetical survival of the study cohort, which showed that in an "ideal scenario" of ICD implantation, the mortality in the study cohort was decreased by 6.9% and 12.3% at 2- and 5-year follow-up, respectively. This study highlights the underutilization of ICDs and the referring physicians' approach to this therapy.

Sensing performance of a new wireless implantable loop recorder: a 12-month follow up study.

BACKGROUND: The implantable loop recorder (ILR) is a cost-effective tool with a high diagnostic yield in the evaluation of unexplained recurrent syncope. The Sleuth ILR (Transoma Medical, St. Paul MN, USA) is a new-generation ILR with wireless transmission capability approved by the Food and Drug Administration. We report the feasibility of achieving appropriate sensing over 1-year follow-up at the traditional midclavicular and alternative inframammary implantation sites without preimplant electrocardiogram (ECG) mapping. METHODS AND RESULTS: We studied 32 patients with unexplained syncope, aged 58.4+/-18.44 years, with an ILR implanted at the left midclavicular location (n = 17) or the left inframammary site (n = 15) over 1-year post implant. No preimplant electrocardiogram (ECG) mapping was performed. The highest R-wave amplitudes were observed at the inframammary site, but over the entire follow-up period, amplitudes were not significantly different from those at the midclavicular site. At both sites, R-wave amplitudes at the 6-month follow-up were significantly higher than those measured at 1 week. P-waves were visible in 80-90% of the patients. There was no discernible difference in P-waves (amplitude) relative to implant location. Body mass index, left ventricular ejection fraction, and age did not significantly influence the R-wave amplitude or the ability to discern P-waves. CONCLUSION: Our findings show that the Sleuth ILR implanted at both the midclavicular and inframammary locations without preimplant ECG mapping achieves acceptable "R" waves. This may simplify implantation procedures and improve patient satisfaction.