Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease: A Multicenter Study.

Mixed aortic valve disease (MAVD), defined by the concurrent presence of aortic stenosis (AS) and insufficiency is frequently seen in patients who have undergone transcatheter aortic valve implantation (TAVI). However, studies comparing the outcomes of TAVI in MAVD versus isolated AS have demonstrated conflicting results. Therefore, we aim to assess the outcomes of TAVI in patients with MAVD in comparison with those with isolated severe AS. Patients who underwent native valve TAVI for severe AS at 3 tertiary care academic centers between January 2012 and December 2020 were included and categorized into 3 groups based on concomitant aortic insufficiency (AI) as follows: group 1, no AI; group 2, mild AI; and group 3, moderate to severe AI. Outcomes of interest included all-cause mortality and all-cause readmission rates at 30 days and 1 year. Other outcomes include bleeding, stroke, vascular complications, and the incidence of paravalvular leak at 30 days after the procedure. Of the 1,588 patients who underwent TAVI during the study period, 775 patients (49%) had isolated AS, 606 (38%) had mild AI, and 207 (13%) had moderate to severe AI. Society of Thoracic Surgeons risk scores were significantly different among the 3 groups (5% in group 1, 5.5% in group 2, and 6% in group 3, p = 0.003). Balloon-expandable valves were used in about 2/3 of the population. No statistically significant differences in 30-day or 1-year all-cause mortality and all-cause readmission rates were noted among the 3 groups. Post-TAVI paravalvular leak at follow-up was significantly lower in group 1 (2.3%) and group 2 (2%) compared with group 3 (5.6%) (p = 0.01). In summary, TAVI in MAVD is associated with comparable outcomes at 1 year compared with patients with isolated severe AS.

Current Perspectives on Coronavirus Disease 2019 and Cardiovascular Disease: A White Paper by the JAHA Editors.

Coronavirus Disease 2019 (COVID-19) has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020. In this White Paper, we address the cardiovascular co-morbidities of COVID-19 infection; the diagnosis and treatment of standard cardiovascular conditions during the pandemic; and the diagnosis and treatment of the cardiovascular consequences of COVID-19 infection. In addition, we will also address various issues related to the safety of healthcare workers and the ethical issues related to patient care in this pandemic.

Necrotizing Autoimmune myopathy: A case report on statin induced rhabdomyolysis requiring immunosuppressive therapy.

Statins can cause a wide spectrum of muscular adverse effects ranging from asymptomatic elevation of Creatine Kinase (CK), myalgia and exercise intolerance to rhabdomyolysis. Most of these effects generally resolve on stopping the medication. However, statins can be associated with a unique autoimmune myopathy wherein symptoms persist or even progress after statin discontinuation and require immunosuppressive therapy. The case presented is a 60-year-old woman who was on statin treatment for a period of 2 years. She developed muscle weakness with a limb girdle distribution. She had persistent elevation of CK even after discontinuation of statin therapy. EMG done revealed irritable myopathy and muscle biopsy showed necrosis without inflammation. She subsequently tested positive for anti-3-hydroxy-3-methylglutaryl-coenzyme A (anti-HMG CoA) antibody which is found to be present in patients with statin-associated necrotizing autoimmune myopathy. Patient was started on steroid without much improvement in her symptoms. After a month of follow up, her upper extremity strength was back but lower extremity continued to be weak which prompted us to start her on Methotrexate and Azathioprine. Like our patient, there are rare subgroup of patients with an immune-mediated necrotizing myopathy that does not improve after discontinuation of the drug and requires aggressive treatment with immunosuppressive agents. Awareness and early recognition of this disease is very important in patients who continue to have CK elevation and weakness after discontinuation of statin therapy.

Sacubitril/valsartan: A novel angiotensin receptor-neprilysin inhibitor.

OBJECTIVE: To describe the efficacy, superiority and safety profile of the first-in-class angiotensin receptor-neprilysin inhibitor "Sacubitril/Valsartan" as compared to angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blocker (ARB) in heart failure (HF) patients, reviewing data available from both clinical and pre-clinical studies. Evidences on health care utilization outcomes such as hospitalizations and emergency department visits were also evaluated. MATERIAL (DATA SOURCE): Sources: Medical literature on 'Sacubitril/Valsartan' and 'Angiotensin Receptor-Neprilysin Inhibitor' was identified by searching databases (including, but not limited to, PubMed, Embase and HighWire) for articles published since 1991, bibliographies from published literature, clinical trial registries/databases and websites (including those of regional regulatory agencies and the manufacturer). Additional information (including contributory unpublished data) was also requested from the companies developing the drug. SEARCH STRATEGY: We conducted separate searches for each of the interventions of interest. The timeframe for both searches spanned the period from January 1991 to the most recently published data available and focused on PubMed, Embase and HighWire indexed articles. The search strategies included a combination of indexing terms as well as free-text terms included separately in 'Keywords' section. To supplement the above searches and ensure optimal and complete literature retrieval, we performed a manual check of the references of recent relevant reviews and meta-analysis. Searches were last updated on 12th July 2017. SELECTION: Studies in patients with hypertension who received sacubitril/valsartan combination drug were included. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well-controlled trials with appropriate statistical methodology was preferred. Relevant pharmacodynamics and pharmacokinetics data was also included. DATA EVALUATION: Many clinical trials have been conducted comparing the efficacy of sacubitril/valsartan with other anti-hypertensives. The trials have shown sacubitril/valsartan to be more effective in improving symptoms and physical limitations, reducing the risk of cardiovascular (CV) death, HF hospitalization, and the overall mortality and morbidity compared to its counterparts. CONCLUSION: Effective reduction of blood pressure to accepted goals is the key to reduce the risk of CV events and stroke. Dual inhibition of neprilysin and the angiotensin receptor with sacubitril/valsartan may represent an attractive and serendipitous therapeutic approach for a range of CV diseases, including hypertension and HF, in which vasoconstriction, volume overload and neuro-hormonal activation play a part in pathophysiology. Sacubitril/Valsartan appears to be more efficacious in reducing blood pressure than currently available ACEi and ARBs with a similar safety and tolerability profile. Besides, pleiotropic benefits like HbA1c reduction, better eGFR progression and a greater decrease in blood pressure and serum creatinine levels make this drug a novel addition to the current hypertension armamentarium.

A Rare Case of Isolated Left Ventricular Non-compaction in an Elderly Patient.

A 61-year-old male, with a history of emphysema, obstructive sleep apnea, and hypertension, presented to the emergency room with worsening shortness of breath over a three-month period. The patient also complained of orthopnea, paroxysmal nocturnal dyspnea, and progressively worsening lower limb swelling. On examination, the patient had jugular venous distension, bilateral lower extremity edema, and bibasilar crackles. The laboratory evaluation showed an elevated B-natriuretic peptide level and a normal troponin level. A transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction (LVEF) of 20%-25% with prominent hyper-trabeculations noted in the left ventricle, most prominent in the lateral and apical walls. These findings were concerning for left ventricular non-compaction (LVNC). The patient underwent left heart catheterization, which did not show obstructive coronary disease as a cause of his cardiomyopathy. The patient was managed with guideline-directed therapy for heart failure and was started on warfarin due to the increased risk of thromboembolism associated with LVNC. During his admission, he exhibited multiple episodes of nonsustained ventricular tachycardia and was subsequently evaluated by electrophysiology (EP). He was discharged home with a wearable cardioverter defibrillator with instructions to follow up with EP in three months for an evaluation of implantable cardioverter-defibrillator (ICD) placement for primary prevention.

Chronic obstructive pulmonary disease and the hallmarks of aging.

Aging is characterized by progressive deterioration of physiological integrity, decline in homeostasis, and degeneration of the tissues that occurs after the reproductive phase of life is complete, leading to impaired function. This deterioration is an important risk factor for chronic lung pathologies such as chronic obstructive pulmonary disease (COPD). COPD is a disease that develops gradually. Emphysematous changes in the lung take years to develop after exposure to cigarette smoke; hence, the vast majority of patients are elderly. There has been a dramatic increase in the life expectancy of the general population, resulting in an increased burden of chronic lung diseases. There is growing evidence that molecular mechanisms involved in aging may also play a role in COPD pathogenesis. Recently, the nine hallmarks of aging were identified. In this article, we will review the nine hallmarks of aging and how each hallmark contributes to the pathogenesis of COPD.

Campylobacter jejuni and Pseudomonas coinfection in the setting of ulcerative colitis.

A 66-year-old woman presented with 2 days of fever and severe diarrhoea. She has a history of ulcerative colitis (UC), well controlled with medication. She also has a history of Ehlers-Danlos syndrome, infective endocarditis following aortic valve replacement and pulmonary embolism. She had complained of passing stool with traces of blood about 30 times per day. Stool testing for Clostridium difficile, routine culture and microscopy was done. She was started on ceftriaxone. CT scan revealed thick-walled colon consistent with UC flare. Flexible sigmoidoscopy showed active continuous colitis extending from the rectum to the proximal descending colon. Campylobacter jejuni was isolated from the stool and blood cultures yielded Pseudomonas aeruginosa. The antibiotic was transitioned to intravenous piperacillin/tazobactam and azithromycin followed by 2 weeks of intravenous cefepime. Her diarrhoea was controlled, and she was discharged for follow-up in 2 months.

Ureteritis Cystica: An Unusual Presentation in an Otherwise Healthy Female.

A 23-year-old, previously healthy female presented with lower abdominal pain and mildly elevated creatinine one month following a right ureter stent for non-specific ureteral thickening causing obstruction. On admission, computed tomography (CT) revealed moderate hydronephrosis of the left kidney that would require stent placement as well. During stent placement, it was noted that the gross appearance of the ureters resembled ureteritis cystica. Biopsies were taken and showed signs of chronic inflammatory changes consistent with this diagnosis. Interestingly, this patient had no obvious medical history suggesting a cause for this process. She had been otherwise healthy with no recurrent episodes of urinary tract infection, nephrolithiasis, or sexually transmitted infection. The patient was discharged symptom-free following stent placement and will follow with urology for future stent replacements and clinical monitoring.

Multiple Primary Malignant Neoplasms in an Elderly Patient.

Only a few case reports to date have described patients with three or more cancers. However, the incidence of multiple primary malignancies is increasing due to the improved survival of cancer patients, the prolonged lifespan of the general population, and better diagnostic techniques. This report describes a 73-year-old woman with primary breast, rectal squamous cell, and renal cell carcinomas. This case is unique because, in addition to having three primary malignancies, this patient had rectal squamous cell carcinoma-one of the rarest types of rectal cancer. We discuss screening and prevention of multiple malignancies and rectal squamous cell carcinoma, as well as methods for managing these patients.

Acromegaly with Dilated Cardiomyopathy.

Acromegaly is a rare condition with an approximate incidence of 3-4 new cases per million per year and occurs as a result of excess secretion of growth hormone (GH). It is associated with several cardiovascular manifestations of which dilated cardiomyopathy with systolic and diastolic dysfunction is relatively rare but associated with increased mortality. There are very few documented cases of acromegaly with dilated cardiomyopathy in Indian female patients in literature, thus justifying the uniqueness of our case. We report a case of acromegaly in a 41 year old female patient who remained undiagnosed for 6 years and presented to us for the first time with symptoms of heart failure. The symptoms were attributed to dilated cardiomyopathy resulting from a prolonged and excessive exposure of the myocardium to a GH secreting pituitary tumor. Subsequently she underwent trans-sphenoidal resection of the pituitary macroadenoma.

Azilsartan: Novel Angiotensin Receptor Blocker.

OBJECTIVE: To describe the efficacy and safety profile of the new angiotensin receptor blocker (ARB), "Azilsartan Medoxomil", reviewing data available from both clinical and pre-clinical studies. MATERIAL: We completed a review of the English literature from PubMed using the keywords- azilsartan medoxomil, angiotensin receptor blockers (ARB), angiotensin converting enzyme inhibitors (ACEi) and hypertension. DATA EVALUATION: Many clinical trials have been conducted comparing the efficacy of azilsartan with other ARB's and also with the ACEi ramipril. The trials have shown azilsartan to be more effective in reducing the mean 24-hour systolic blood pressure compared to its counterparts. CONCLUSIONS: Azilsartan is a recently approved ARB and appears to be more efficacious in reducing blood pressure (BP) than the other ARBs with a similar safety and tolerability profile. Azilsartan's very high affinity to and slow dissociation from the angiotensin 1 receptor (AT1R) along with its inverse agonistic properties make it a very good candidate for clinical effects beyond simple BP control, potentially counteracting cardiac hypertrophy, cardiac fibrosis and insulin resistance, together with improved reno-protection and atherosclerotic plaque stabilization.

Cannabinoid hyperemesis syndrome.

The antiemetic properties of marijuana are well known, but there is increasing evidence of its paradoxical hyperemetic effects on the gastrointestinal tract and central nervous system, known as 'cannabinoid hyperemesis syndrome' (CHS). We report a case of CHS encountered in our outpatient clinic. We also completed a review of the literature using PubMed in patients over 18 years of age with CHS. Understanding the diagnostic criteria and risk factors associated with CHS may reduce the ordering of unnecessary and expensive investigations, and pursuing inappropriate medical and surgical treatments. Ultimately, abstaining from cannabis use leads to resolution of symptoms in the majority of patients.