Quantification of hs-Troponin Levels and Global Longitudinal Strain among Critical COVID-19 Patients with Myocardial Involvement.

Background. Myocardial involvement among critically ill patients with coronavirus disease 2019 (COVID-19) often has worse outcomes. An imbalance in the oxygen supply causes the excessive release of pro-inflammatory cytokines, which results in increased ventilation requirements and the risk of death in COVID-19 patients. Purpose. We evaluated the association between the hs-troponin I levels and global longitudinal strain (GLS) as evidence of myocardial involvement among critical COVID-19 patients. Methods. We conducted a prospective cohort study from 1 February to 31 July 2021 at RSUD Dr. Soetomo, Surabaya, as a COVID-19 referral center. Of the 65 critical COVID-19 patients included, 41 (63.1%) were men, with a median age (interquartile range) of 51.0 years (20.0-75.0). Subjects were recruited based on WHO criteria for severe COVID-19, and myocardial involvement in the form of myocarditis was assessed using CDC criteria. Subjects were examined using echocardiography to measure the GLS, and blood samples were taken to measure the hs-troponin. Subjects were then followed for their need for mechanical ventilation and in-hospital mortality. Results. Severe COVID-19 patients with cardiac injury were associated with an increased need for intubation (78.5%) and an increased incidence of myocarditis (50.8%). There was a relationship between the use of intubation and the risk of death in patients (66.7% vs. 33.3%, p-value < 0.001). Decreased GLS and increased hs-troponin were associated with increased myocarditis (p values < 0.001 and 0.004, respectively). Decreased GLS was associated with a higher need for mechanical ventilation (12.17 + 4.79 vs. 15.65 + 4.90, p-value = 0.02) and higher mortality (11.36 + 4.64 vs. 14.74 + 4.82; p-value = 0.005). Elevated hs-troponin was associated with a higher need for mechanical ventilation (25.33% vs. 3.56%, p-value = 0.002) and higher mortality (34.57% vs. 5.76%, p-value = 0.002). Conclusions. Critically ill COVID-19 patients with myocardial involvement and elevated cardiac troponin levels are associated with a higher need for mechanical ventilation and higher mortality.

Rapid Atrial Fibrillation in the Emergency Department.

Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.

A "Ping-Pong" left atrial thrombus mimicking left atrial myxoma: A case report.

Introduction: Valvular heart disease is highly prevalent, especially in developing countries. Mitral Stenosis (MS) is a condition where there is narrowing of mitral heart valve. Left atrial (LA) thrombus is often seen in severe MS patients. Case presentation: A 47-year-old woman complained of palpitation and shortness of breath. The heart sounded irregularly irregular, with grade III/IV diastolic murmurs at the apex. Her electrocardiogram showed atrial fibrillation (AF) with rapid ventricular response Transthoracal echocardiography (TTE) showed severe MS, mild tricuspid regurgitation, and LA thrombus. Mitral valve replacement surgery, tricuspid valve repair, and evacuation of the LA thrombus were immediately done. We evacuated a spherical mass with a size of 4 × 3x2.2 cm, layered and easily separated. Microscopic examination showed extensive fibrin and bleeding with mononuclear inflammatory cells and macrophages, corresponding to a thrombus conclusion. Clinical discussion: Atrial thrombus is common in MS patients. The incidence will increase by about two times in patients with AF. TTE is a reliable tool in diagnosing large mobile atrial thrombus and differentiated it from other cardiac masses. However, histopathological examination is still the gold standard to distinguish between LA thrombus and myxoma. Immediate thrombus evacuation and valve replacement, if needed, will give good results and reduce systemic thromboembolism. Conclusion: LA thrombus is often seen in a patient with severe MS. Optimal preoperative preparation involves assessing preoperative risk stratification will give good results.

Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series.

BACKGROUND: True isolated posterior myocardial infarction is an uncommon finding of acute coronary syndrome, with an incidence rate of 3-7%. The prevalence rates of isolated posterior myocardial infarction in men and women are 72% and 28%, respectively. This uncommon finding may be attributed to multiple factors, such as unremarkable changes on 12-lead electrocardiography, a lack of awareness or knowledge, and an absence of diagnostic consensus, which leads to reperfusion delay and poor clinical outcomes. Herein, we report three cases of acute myocardial infarction presenting as isolated ST-segment elevation in the posterior leads (V7-V9): Asian men aged 57, 62, and 53 years, who presented with ST-segment depression in V1-V3 that resolved gradually. Coronary angiography revealed a total/critical occlusion of the proximal circumflex coronary artery in all three cases. Routine and accurate interpretations of 15-lead electrocardiography (12-lead with additional V7-V9) resulted in a better sensitivity for isolated posterior myocardial infarction diagnoses, followed by a timely and opportune primary percutaneous coronary intervention. CONCLUSIONS: Isolated posterior myocardial infarction is a rare but potentially fatal event that is often accompanied by atypical and subtle changes on 12-lead electrocardiography (especially in the V1-V3 precordial leads) and may remain undetected by physicians. Therefore, the comprehensive and routine application of posterior leads is a crucial addition to the standard diagnosis and management of acute coronary syndrome in patients with subtle ST-segment changes who do not fulfill the criteria for ST-elevation myocardial infarction.

Association between donor's age and expression of cardiomyocyte marker quantity on adipocyte-derived mesenchymal stem cell.

Aim Adipocyte-derived mesenchymal stem cells (AMSCs) have recently been studied as a potential new approach for regeneration treatment of heart failure and ischemic myocardium. However, donor's age is thought to affect the ability of AMSC cells to differentiate into cardiomyocytes. This study aimed to analyse the association between donor's age with the expression of cardiomyocyte marker cardiac isoform of Troponin-T (cTnT) quantity on AMSCs. Methods Subcutaneous adipose tissue was taken from donors of 3 different age groups (30-40, 41-50, and >50 years old), and then processed into AMSC cells by insert culture. AMSC cell phenotype was identified by assessing the quantity of mesenchymal markers expression (CD34, CD45, CD90, CD105) using indirect immunofluorescence technique. Afterwards, cTnT expression, a marker for cardiomyocyte differentiation from AMSC cells, was evaluated under the fluorescent microscope. The comparison was done between the 3 different age groups. Results The comparative test and post hoc analysis showed that there were differences in the expression of CD34, CD45, CD90, CD105, and cTnT between the three age groups (all p<0.05). Furthermore, there were strong negative correlations between age and CD34, CD90, CD105 and cTnT (r= -0.844, -0.914, -0.899, and -0.738, respectively), while the correlation was positive between age and CD45 (r=0.899). Conclusion Expression quantity of mesenchymal markers and cardiomyocyte markers from AMSC cells were affected by the donor's age. The higher the donor age group, the lower the expression quantity of mesenchymal markers (except CD45) and cTnT.

Serum uric acid and the risk of ventricular arrhythmias: a systematic review.

Uric acid (UA) is the end product of purine degradation in humans. It promotes inflammation via activation of pro-inflammatory cytokines and increases oxidative stress. The serum uric acid level has emerged as an independent risk factor of cardiovascular disease such as ventricular arrhythmias (VA). Here we had done a systematic review to assess the association between serum UA levels and the occurrence of VA. This systematic review included a total of four clinical studies with 99.383 patients for analysis. The scientific quality of all four studies was good. Three studies showed that serum uric acid levels were associated with VA in many populations. In contrast, one study with a large sample size evaluated that serum uric acid increases premature ventricle contraction prevalence. A significant association between serum uric acid level and VA was found in four studies (p<0.01; p<0.101; p=0.002; p=0.008). In conclusion, this systematic review shows an association between serum UA levels and VA.

Vasoplegia: Mechanism and Management Following Cardiopulmonary Bypass.

Vasoplegia is defined by hypotension and low systemic vascular resistance despite the normal or elevated cardiac index, a complication frequently following cardiac surgery, carrying high morbidity and mortality rate. Vasoplegia is related with a profound systemic inflammatory response and is mainly mediated by cellular hyperpolarization, a relative vasopressin deficiency, and high levels of inducible nitric oxide, following cardiopulmonary bypass. Cardiopulmonary bypass is a distinct precipitant of vasoplegia, generally due to its association with nitric oxide production and severe vasopressin depletion. Postoperative vasoplegia is usually managed with vasopressors, of which catecholamines are the traditional agents of choice. Recent studies promote the use of non-catecholamine vasopressor (vasopressin) in restoring systemic vascular resistance. Alternative agents are also able to restore vascular tone and improve vasoplegia, including methylene blue, angiotensin II, hydroxocobalamin, and ascorbic acid; however, their effect on patient outcomes is still unclear .

Electrocardiography on admission is associated with poor outcomes in coronavirus disease 2019 (COVID-19) patients: A systematic review and meta-analysis.

BACKGROUND: Electrocardiogram (ECG) is a widely accessible diagnostic tool that can easily be obtained on admission and can reduce excessive contact with coronavirus disease 2019 (COVID-19) patients. A systematic review and meta-analysis were performed to evaluate the latest evidence on the association of ECG on admission and the poor outcomes in COVID-19. METHODS: A literature search was conducted on online databases for observational studies evaluating ECG parameters and composite poor outcomes comprising ICU admission, severe illness, and mortality in COVID-19 patients. RESULTS: A total of 2,539 patients from seven studies were included in this analysis. Pooled analysis showed that a longer corrected QT (QTc) interval and more frequent prolonged QTc interval were associated with composite poor outcome ([WMD 6.04 [2.62-9.45], P = .001; I 2:0%] and [RR 1.89 [1.52-2.36], P < .001; I 2:17%], respectively). Patients with poor outcome had a longer QRS duration and a faster heart rate compared with patients with good outcome ([WMD 2.03 [0.20-3.87], P = .030; I 2:46.1%] and [WMD 5.96 [0.96-10.95], P = .019; I 2:55.9%], respectively). The incidence of left bundle branch block (LBBB), premature atrial contraction (PAC), and premature ventricular contraction (PVC) were higher in patients with poor outcome ([RR 2.55 [1.19-5.47], P = .016; I 2:65.9%]; [RR 1.94 [1.32-2.86], P = .001; I 2:62.8%]; and [RR 1.84 [1.075-3.17], P = .026; I 2:70.6%], respectively). T-wave inversion and ST-depression were more frequent in patients with poor outcome ([RR 1.68 [1.31-2.15], P < .001; I 2:14.3%] and [RR 1.61 [1.31-2.00], P < .001; I 2:49.5%], respectively). CONCLUSION: Most ECG abnormalities on admission are significantly associated with an increased composite poor outcome in patients with COVID-19.

Extracorporeal Membrane Oxygenation Used in Acute Respiratory Distress Syndrome with COVID-19: A Systematic Review and Meta-Analysis.

INTRODUCTION: Protective pulmonary mechanical ventilation, higher positive end-expiratory pressure, neuromuscular blockade, prone positioning, and pulmonary recruitment procedures are all strategies in severe COVID-19 cases. Extracorporeal Membrane Oxygenation (ECMO) can be seen as an alternative to traditional treatment in certain patients when conventional therapy fails. We present a study that intends to systematically review and meta-analysis ECMO use in COVID-19 patients. METHODS: We search major medical databases (Cochrane Library, PubMed, EMBASE, MedRxiv) for clinical trials that were released between January 2020 until February 2021, had full-text availability, were written in English, and humans studies.We used National Heart, Lung, and Blood Institute (NHLBI) quality evaluation methods for retrospective cohort and cross-sectional studies to evaluate the quality of the articles. In addition, we used the Mantel-Haenszel random-effects meta-analysis of using RevMan 5.4. RESULTS: A total of 33 studies involving 3090 patients were included in the systematic review and six studies in the meta-analysis. There were 828 patients admitted to the ICU, of which 779 patients had ARDS (94%). Of the total study, 527 patients received ECMO therapy (17%). ARDS incidence was associated with complications during ICU care compared to non-ICU care (OR 107.98; 95% CI 55.51-210.03; p < 0.00001). Indirect comparisons, the incidence of mortality was associated with ECMO compared with non-ECMO (OR 15.79; 95% CI 4.21-59.28; p < 0.0001). CONCLUSION: The incidence of ARDS was associated with complications during ICU stay, and the incidence of mortality was associated with ECMO. Further study about mechanisms involving illness and death of patients from COVID-19 is needed.

Evaluation of heart rate variability using 24-hour Holter electrocardiography in hypertensive patients.

BACKGROUND: Hypertension (HTN) remains a serious risk factor for cardiovascular mortality across the world. Hypertensive state has been shown to be associated with autonomic nervous function. This study aimed to explore the association between autonomic nervous impairment assessed by heart rate variability (HRV) and HTN. METHODS: A total of 52 hypertensive and 55 non-hypertensive patients were consecutively studied using 24-hour Holter. The hypertensive patients were grouped into controlled blood pressure (BP) and uncontrolled BP. This study compared HRV in non-hypertensive and hypertensive patients; and hypertensive patients with controlled and uncontrolled BP. HRV parameters include time and frequency domain. RESULTS: Mean age for hypertensive and non-hypertensive patients were 53.58 ± 14.31 and 44.89 ± 16.63 years old, respectively. Median (IQR) SDNN for hypertensive and non-hypertensive group were 109.00 (90.00-145.00) and 129.00 (107.00-169.00), respectively. SDNN, ASDNN, rMSSD, pNN50, BB50, VLF, and HF values were significantly lower in the hypertensive group compared to non-hypertensive group (all P < .05). A multiple regression analysis showed that HRV parameters: SDANN, ASDNN, rMSSD, and LF values were independent risk factors of HTN. SDNN, SDANN, ASDNN, VLF, LF, and HF values were significantly lower in the uncontrolled BP compared to controlled BP group (all P < .05). A multiple regression analysis showed that HRV parameters: SDNN, SDANN, rMSSD, and HF values were independent risk factors of uncontrolled BP in hypertensive patients. CONCLUSIONS: Our study showed that cardiac autonomic nervous impairment, as demonstrated by reduced HRV, is significantly associated with HTN. Decreased HRV was more evident in uncontrolled BP than in controlled BP group.