First Description of Novel End-Organ Effects by Speed Modulation Using the Aortix™ Device.

Aortix™ is a novel percutaneous mechanical circulatory support device designed to facilitate diuresis in patients with cardiorenal syndrome. We describe for the first time the development of end-organ hypoperfusion from excess blood acceleration at the nominal setting and demonstrate through temporal-perfusion marker curves, the potential for speed modulation to optimize results. This will inform future device development and investigation of patient-specific device titration.

Takotsubo Cardiomyopathy in the Setting of Hypertrophic Cardiomyopathy Following Pacemaker Implantation.

The presentation of Takotsubo cardiomyopathy (TC) has overlapping features with acute coronary syndrome (ACS), though traditionally developing from different triggers, including both physical and emotional. Additionally, TC is associated with multiple comorbidities and sequelae. We present a multifactorial case of a 73-year-old female with underlying hypertrophic cardiomyopathy who presented with a high-degree atrioventricular (AV) block requiring permanent pacemaker (PPM) placement and subsequently developed TC. Patients with hypertrophic obstructive cardiomyopathy (HCM) have been theorized to have increased cardiac sympathetic activity and sensitivity. Thus, this case report demonstrates the increased relative risk of patients with underlying HCM in the development of TC during PPM placement.

A Case of Rapid Development of Methicillin­Resistant Staphylococcus aureus Mechanical Aortic Root Abscess Despite Appropriate Antibiotic Use.

A 74-year-old male with a past medical history of mechanical aortic valve replacement presented with abdominal pain and fever. Blood cultures revealed methicillin-resistant Staphylococcus aureus (MRSA) and the patient was started on target antibiotics. Initial transthoracic echocardiogram and transesophageal echocardiogram (TEE) did not show any vegetations or significant valvular regurgitation. No other sources of infection were identified. Five days after the initial TEE, a repeat TEE revealed new areas of thickening and echolucency seen anterior to the mechanical aortic valve, suggestive of aortic root abscess (AoRA). It also extended down the mitral-aortic intervalvular fibrosa and was associated with mitral valvular vegetation.  Due to worsening clinical status and persistent bacteremia on appropriate antibiotics, a high index of suspicion for infective endocarditis (IE) remained after the initial TEE. As such, the repeat TEE was obtained only five days after and demonstrated clear evidence of rapidly growing endocarditis and abscess formation. This case uniquely demonstrates how rapid MRSA endocarditis may progress and emphasizes its high mortality. This case highlights the importance of a low threshold for repeat imaging when the index of suspicion for endocarditis remains high despite negative imaging.

Cardiovascular Events Among Adults Treated With Chimeric Antigen Receptor T-Cells (CAR-T).

BACKGROUND: Chimeric antigen receptors redirect T cells (CAR-T) to target cancer cells. There are limited data characterizing cardiac toxicity and cardiovascular (CV) events among adults treated with CAR-T. OBJECTIVES: The purpose of this study was to evaluate the possible cardiac toxicities of CAR-T. METHODS: The registry included 137 patients who received CAR-T. Covariates included the occurrence and grade of cytokine release syndrome (CRS) and the administration of tocilizumab for CRS. Cardiac toxicity was defined as a decrease in the left ventricular ejection fraction or an increase in serum troponin. Cardiovascular events were a composite of arrhythmias, decompensated heart failure, and CV death. RESULTS: The median age was 62 years (interquartile range [IQR]: 54 to 70 years), 67% were male, 88% had lymphoma, and 8% had myeloma. Approximately 50% were treated with commercial CAR-T (Yescarta or Kymriah), and the remainder received noncommercial products. CRS, occurring a median of 5 days (IQR: 2 to 7 days) after CAR-T, occurred in 59%, and 39% were grade ≥2. Tocilizumab was administered to 56 patients (41%) with CRS, at a median of 27 h (IQR: 16 to 48 h) after onset. An elevated troponin occurred in 29 of 53 tested patients (54%), and a decreased left ventricular ejection fraction in 8 of 29 (28%); each occurred only in patients with grade ≥2 CRS. There were 17 CV events (12%, 6 CV deaths, 6 decompensated heart failure, and 5 arrhythmias; median time to event of 21 days), all occurred with grade ≥2 CRS (31% patients with grade ≥2 CRS), and 95% of events occurred after an elevated troponin. The duration between CRS onset and tocilizumab administration was associated with CV events, where the risk increased 1.7-fold with each 12-h delay to tocilizumab. CONCLUSIONS: Among adults, cardiac injury and CV events are common post-CAR-T. There was a graded relationship among CRS, elevated troponin, and CV events, and a shorter time from CRS onset to tocilizumab was associated with a lower rate of CV events.

Significance of Obstetrical History with Future Cardiovascular Disease Risk.

The maternal cardiovascular system undergoes profound changes to support the increasing demands of fetal growth during pregnancy. An accumulating body of evidence has shown that common pregnancy complications, including gestational diabetes mellitus, preeclampsia, low birth weight, and preterm delivery, can be associated with future cardiovascular adverse events in mothers. Factors such as glucose metabolism, hyperlipidemia, inflammatory markers, and large- and small-vessel stiffness/functionality have been linked with these pregnancy conditions. Critically, there are no established guidelines to account for these maternal factors when considering future cardiovascular disease risk, one of the leading causes of female mortality. This article reviews the study of cardiovascular disease and pregnancy, and proposes possible connections that should spur future investigation in an area of medicine that requires significant research.

Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study.

BACKGROUND: Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated. METHODS: In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer's exact at the significance level of 0.05. RESULTS: Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001). CONCLUSION: Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period.

Alkaptonuria.

A 50-year-old woman with a chronic polyarthropathy was seen by her orthopedist for long-standing back and shoulder and worsening hip pain. A lateral labral tear and chronic trochanteric bursitis were diagnosed on hip magnetic resonance imaging, which was otherwise unremarkable. Hip arthroscopy was performed revealing an unusual bluish-tinged femoral head articular surface. Computed tomography scans of the spine were also obtained.