Concurrent spontaneous coronary dissection and reversible cerebral vasoconstriction syndrome during postnatal care.

BACKGROUND: Pregnancy-associated spontaneous coronary artery dissection (SCAD) and reversible cerebral vasoconstriction syndrome (RCVS) are rare conditions that may occur during pregnancy and the postpartum period. The coexistence of both diseases may pose a risk to patients, potentially resulting in a variety of complications and clinical manifestations. This is considered the first case of a patient who successfully recovered from a critical condition in the postpartum period, with contemporaneous SCAD and RCVS. CASE PRESENTATION: A 33-year-old female with no known medical history was referred to the emergency department after experiencing cardiac arrest, which occurred 1 week after giving birth to her third child. She complained of sudden anterior squeezing chest pain, accompanied by a headache, and eventually collapsed due to ventricular fibrillation with seizure. She was successfully resuscitated after receiving basic life support. She showed an alert mentality and did not experience any further seizure events or additional neurological symptoms. Although vital sign remained stable, the level of highly sensitive troponin I was significantly elevated. Electrocardiography revealed sinus rhythm with T-wave inversion at V1-4, while chest computed tomography (CT) demonstrated severe aspiration pneumonia. The patient was admitted to the intensive care unit due to a high requirement of O2 supply. A consultation with the neurologic department and a brain magnetic resonance angiography (MRA) were conducted for the thunderclap headache. The brain MRA demonstrated stenosis in the basilar artery, the right M2 segment, and bilateral A1 segments, along with sulcal hyperintensity on post-contrast fluid-attenuated inversion recovery (FLAIR) suggesting blood-brain barrier breakdown due to vasoconstriction. Formal echocardiography showed regional wall motion abnormality in the left anterior descending artery (LAD) territory. After the improvement of pneumonia, a coronary angiography was performed, revealing diffuse luminal narrowing from the mid to distal LAD due to a long segmental, extensive dissection. We decided to maintain the medical therapy. A follow-up coronary CT angiography performed 6 months later revealed complete remission of the dissected coronary vessel, and a brain MRA checked 3 months later showed resolved vasoconstriction of the relevant cerebral vessels. CONCLUSIONS: The physicians must be aware of pregnancy-associated complications in certain patients. Clear diagnoses and proper treatments are required in pregnant patients who may be exposed to multiple acute conditions, in order to reduce complications and achieve favorable outcomes.

A Pilot Study of Pembrolizumab Combined With Stereotactic Ablative Radiotherapy for Patients With Advanced or Metastatic Sarcoma.

OBJECTIVES: Immunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors. METHODS: This is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy. RESULTS: In this study we outline testing the feasibility of adding SBRT to pembrolizumab. CONCLUSION: The ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.

Bovine pericardial versus porcine bioprosthetic mitral valves: results from a Korean Nationwide Cohort Study.

OBJECTIVES: Comparisons of long-term clinical outcomes of mitral valve replacement (MVR) between bovine pericardial and porcine bioprostheses are conflicting, with limited research in large-scale real-world clinical settings. This study examined clinical outcomes in MVR according to bioprosthesis type using a national administrative claims database. METHODS: This study included adult patients undergoing bioprosthetic MVR between 2003 and 2018 using administrative health care data from the Korean National Health Insurance Service database. Propensity score matching with competing risk analysis was used to compare the clinical outcomes according to the type of bioprosthesis. The end points were death, cardiac death, and valve-related events, including the incidence of reoperation, endocarditis, systemic thromboembolism, and major bleeding. RESULTS: A total of 3151 patients underwent bioprosthetic MVR with bovine pericardial (n = 1628, 51.7%) or porcine (n = 1523, 48.3%) bioprostheses. After matching, 1170 pairs were included in the final analysis. During follow-up (median 4.49 years, interquartile range 1.87 -8.75 years), death occurred in 1178 patients (6.8%/patient-year), comprising 730 (4.3%/patient-year) cardiac death. No significant differences were noted between the bovine and porcine groups in the cumulative incidences of death from any cause [adjusted hazard ratio (aHR), 1.00; 95% confidence interval (CI), 0.87-1.14], cardiac mortality (aHR, 0.96; 95% CI, 0.81-1.14), or reoperation (aHR, 1.01; 95% CI, 0.72-1.41). CONCLUSIONS: This study on a nationwide comparison between bovine and porcine bioprostheses in MVR found no significant differences in clinical outcomes including mortality, and valve-related reoperation.

Endovascular treatment of Takayasu arteritis in a middle-aged woman with syncope and limb claudication: a case report.

Takayasu arteritis (TA) is a disease that causes inflammation and stenosis of medium to large blood vessels. We report a case of a 50-year-old female patient with newly developed hypertension, syncope, and claudication of the extremities. Total occlusion of the left subclavian artery at the origin was found and significant stenosis of the right common iliac artery was revealed by hemodynamic analysis. She was successfully treated with percutaneous angioplasty for multiple peripheral arterial diseases and was finally diagnosed with TA. In consultation with a rheumatologist, medical treatment for TA was initiated, the patient's hypertension disappeared, and her claudication symptoms improved.

Long-term outcomes and prognostic factors after aortic valve surgery in patients with Takayasu arteritis.

BACKGROUND: Aortic regurgitation (AR) is a common cardiovascular complication in patients with Takayasu arteritis (TAK), and complication after aortic valve surgery (AVS) is not rare. This study aimed to identify the long-term postoperative outcomes for significant AR in patients with TAK compared with those in patients without TAK. METHODS: We included 35 patients with TAK with moderate-to-severe AR who underwent AVS and compared their postoperative outcomes with those of 105 age- and operation period-matched patients with severe AR but without TAK. The risk factors for poor outcomes [all-cause death and major adverse cardiac and cerebrovascular events (MACCE)] in patients with TAK were analyzed using multivariate Cox regression. RESULTS: The 10-year overall survival rate was 70.5% in patients with TAK and 89.4% in those without TAK (p = 0.048). The MACCE and reoperation rates were significantly higher in patients with TAK (10-year freedom from MACCE, 58.2% vs. 86.4% [p < 0.001]; 10-year freedom from reoperation, 64.5% vs. 98.3% [p < 0.001]). Eighteen of the 35 patients with TAK (51.4%) had poor outcomes, and multivariate analysis revealed that significant coronary artery involvement [hazard ratio (HR), 4.178; 95% confidence interval (CI), 1.222-14.282; p = 0.023] and decreased estimated glomerular filtration rate (HR, 0.968; 95% CI 0.947-0.989; p = 0.003) were associated with poor outcomes. CONCLUSION: The long-term postoperative outcomes for AR were poorer in patients with TAK than in those without TAK. The poor outcomes in patients with TAK were associated with coronary artery involvement and decreased renal function.

Audiometric and Surgical Outcomes of a Novel Bone-Conduction Hearing Aid.

OBJECTIVE: To report the audiometric and surgical outcomes of a series of patients having undergone implantation of a novel transcutaneous bone conduction implant (t-BCI). STUDY DESIGN: Retrospective case series. SETTING: Single academic tertiary referral center. PATIENTS: Adults (≥18 yr) implanted between December 1, 2019, and August 1, 2021, with audiometric data available before and after device implantation and a minimum of 4 weeks follow-up. INTERVENTIONS: Surgical t-BCI. MAIN OUTCOME MEASURES: Change in aided pure tone average (PTA) after implantation. Secondary outcomes include average operative time, and adverse events. RESULTS: Twenty-three patients underwent implantation of the t-BCI via either a conventional or minimally invasive surgical approach. The most common indication for implantation was unilateral conductive hearing loss with a history of chronic otitis media. The mean operative time was 59 minutes. The mean preimplantation unaided air conduction PTA was 65 dB, and mean postimplantation was 27.2 dB. The mean change in PTA was 37.8 dB, which was significant ( p < 0.0001). There were 30.4% of the patients that suffered from adverse events, the most common of which were pain (8.7%) and device-related complications (13%). One major adverse event occurred, involving magnet displacement that impaired device activation and required reoperation for replacement. CONCLUSION: Forming the largest series of patients implanted with this t-BCI in the published literature, our data demonstrate that implantation of the device is feasible via either a traditional or minimally invasive surgical approach, with good audiometric benefit and a favorable safety profile.

The long-term prognostic value of E/e' in patients with ST segment elevation myocardial infarction.

OBJECTIVES: This study aimed to evaluate the long-term prognostic value of E/e' ratio in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We retrospectively assessed 314 patients who underwent primary coronary interventions between January 2010 and December 2015. The included patients were classified into two groups according to the E/e' ratios: E/e'<15 (n = 245) and E/e'≥15 (n = 69). We investigated the incidence of major adverse cardiac events (MACEs) from the event to the final follow-up period of at least three years. RESULTS: A total of 55 cases of MACEs occurred during the follow-up. The E/e'≥15 group showed a significantly higher rate of MACEs than the E/e'<15 group (34.8% vs. 12.7%, p < 0.001). Among the MACE, the percentage of cardiac deaths (17.4% vs. 0.4%, p < 0.001) was higher in the E/e'≥15 group than in the E/e'<15 group. In the multivariable model, E/e'≥15 was demonstrated as the strongest prognostic factor for MACEs (hazard ratio [HR], 2.597; 95% confidence interval [CI], 1.294-5.211; p = 0.007) and cardiac death (HR, 27.537; 95% CI, 3.287-230.689; p = 0.002), while left ventricular ejection fraction (LVEF) was not. Neither the discrepancy of systolic nor diastolic function between initial and follow-up echocardiography affected the overall prevalence of MACEs. A disparity was observed between the two groups, with a significant increase in the rate of MACEs in the E/e'≥15 group (log-rank test, p < 0.001). CONCLUSION: The baseline E/e'≥15 in patients with STEMI after successful reperfusion is the strongest predictor of poor long-term clinical outcomes among those analyzed.

Mechanical and Pore Properties of Concrete Using Basalt-Based Recycled Aggregates According to Mixture Conditions.

This study investigated recycled aggregates of Jeju Island-where porous basalt exists as a natural aggregate-and is a study aimed at verifying the applicability of the basalt-based recycled aggregate in the field. To this end, the application properties of concrete were analyzed using the quality improvement of the recycled aggregate (PRA), the type of fine aggregate received in the region, and the cement content as variables. In an experiment using concrete in which 50% of the PRA was replaced with basalt (BA), the air content of the fresh concrete decreased due to the increasing solid content of the aggregate when PRA and fine aggregates (with an even particle size distribution) were used. Regarding the properties of the hardened concrete, when the PRA and fine aggregate (with a high fineness modulus) were used, the compressive strength was 33.6 MPa and the modulus of elasticity was 23.1 GPa, which are higher than those of the BA specimen. The resistance to carbonation increased due to the improved quality of the PRA specimen. Pores that are 0.3 mm in size or larger decreased when the PRA and fine aggregates of even particle sizes were used. This form of pore reduction was found to have a direct correlation with the improvement of mechanical properties.

Study on Mechanical Properties of Concrete Using Basalt-Based Recycled Aggregate and Varying Curing Conditions.

To replace porous basalt, the mechanical properties of concrete with recycled resources and durability improvement were analyzed in this study. The analysis was based on the quality improvement of recycled aggregate, use of fly ash, and changes in curing conditions. Basalt aggregate (BA) with a 3% water absorption, raw recycled aggregate and basalt (RRA), and improved recycled aggregate and basalt (PRA) were the main experimental variables. As PRA was applied to concrete, the compressive strength was lower than that of the specimen comprising BA in the normal strength region, but the modulus of elasticity (22.9 GPa) was equivalent or higher. The initial drying shrinkage increased because of the use of basalt-based recycled aggregate (B-RA). The drying shrinkage of PRA was similar to that of BA with an average difference of <7% as the age increased. The specimens subjected to steam curing exhibited the lowest drying shrinkage. These results showed that pores in the old paste of recycled aggregate increased freeze−thaw resistance because of the increase in the spacing factor. Although the PRA did not satisfy the quality criteria, the efficient use of recycled aggregate achieved an equivalent or higher performance than that of concrete comprising BA and improved durability.

Spontaneous Resolution of Extensive Iatrogenic Type A Aortic Dissection After Transcatheter Aortic Valve Replacement.

The management of type A aortic dissection (TAAD) during transcatheter aortic valve replacement (TAVR) is challenging because TAVR is often performed in elderly patients with significant surgical risk. We present a case of extensive TAAD that developed during the TAVR procedure, which resolved spontaneously with medical treatment. (Level of Difficulty: Intermediate).

Safety concern with electrical cardioversion of persistent atrial fibrillation with slow ventricular response.

Rhythm control strategies in patients with atrial fibrillation (AF) can bring many clinical benefits. However, there is still uncertainty regarding selection of the optimal rhythm control strategy for persistent AF. Chronicity, substrate alteration, and underlying bradyarrhythmias could influence the clinical outcomes. Current guidelines do not provide a distinct recommendation for electrical cardioversion (ECV) in patients with AF with a slow ventricular response (SVR). We present two cases of sudden cardiac arrest due to sustained ventricular tachycardia/fibrillation after ECV of persistent AF with SVR.

Examination of multiple drug arrests reported to the Maine Diversion Alert Program.

PURPOSE: Much of the responsibility for the increasing drug overdoses in the US has been attributed to opioids but most opioid overdoses also involve another drug. The objective of this study was to identify the drugs involved in polysubstance arrests. The substances that were more likely to be found in conjunction with other substances, using the drug arrests reported to Maine's Diversion Alert Program (DAP) were examined. METHODS: Single and multiple drug arrests were quantified (N = 9,216). Multiple drug arrest percentages were compared to single drug arrest percentages to create a Multiple-to-Single Ratio (MSR) specific to each drug family and each drug to identify over (MSR > 1) and under-representation (MSR < 1). RESULTS: Over three-fifths (63.8%) of all arrests involved a single drug. Opioids accounted for over-half (53.5%) of single arrests, followed by stimulants (27.7%) and hallucinogens (7.7%). Similarly, nearly two-fifths (39.6%) of multiple arrests were for opioids, followed by stimulants (30.8%) and miscellaneous (13.0%). Miscellaneous psychoactive prescription substances (e.g. clonidine, gabapentin, cyclobenzaprine, hydroxyzine) had the highest (1.51) MSR of any drug family. Conversely, stimulants (0.63), opioids (0.42), and hallucinogens (0.35) were significantly underrepresented in polysubstance arrests. Carisoprodol (8.80), amitriptyline (6.34), and quetiapine (4.69) had the highest MSR. Bath-salts (0.34), methamphetamine (0.44), and oxycodone (0.54) had the lowest MSR. CONCLUSION: The misuse of opioids, both alone and in conjunction with another drug, deserves continued surveillance. In addition, common prescription drugs with less appreciated misuse potential, especially carisoprodol, amitriptyline, and quetiapine, require greater attention for their ability to enhance the effects of other drugs.

Different Clinical Features between Definite and Possible Takotsubo Syndrome in a Tertiary Referral Hospital.

BACKGROUND: Although imaging examination to exclude coronary artery disease (CAD) is an indispensable step for a definite diagnosis of takotsubo syndrome (TTS), this step may be overlooked in a substantial proportion of patients with secondary TTS admitted to a tertiary hospital. However, the clinical profiles and outcomes of these patients with "possible TTS" have rarely been investigated. METHODS: Among 420 consecutive TTS patients with characteristic transient ventricular ballooning on repeated echocardiography, 244 patients (58.1%) who underwent an imaging study for CAD were diagnosed with "definite TTS," whereas the remaining 176 were designated with "possible TTS." RESULTS: Overall, hypoxia (67.6%) and dyspnea (55.5%) were predominant presentations. The possible group was characterized by higher prevalence of male gender (46.6% vs. 35.2%, p = 0.019), secondary TTS (97.2% vs. 86.5%, p < 0.001), cancer (43.2% vs. 29.1%, p = 0.003), sepsis (46.0% vs. 32.0%, p = 0.003), and nonapical ballooning pattern (30.7% vs. 21.3%, p = 0.001) with less common ST-segment elevation on electrocardiogram (18.8% vs. 34.0%, p = 0.001). The possible group showed higher frequency of mechanical ventilation (56.2% vs. 40.2%, p = 0.001), pulmonary edema (72.2% vs. 61.5%, p = 0.023), and shock management (70.5% vs. 54.1%, p = 0.001) with similar in-hospital mortality (17.2% vs. 17.0%, p = 0.964). CONCLUSIONS: In real-world clinical practice, coronary evaluation for strict diagnosis of TTS is not frequently feasible. Addition of the possible group without coronary evaluation to the clinical spectrum of TTS would be helpful for fair estimation of clinical implication of TTS.

Mechanical Properties of Basalt-Based Recycled Aggregate Concrete for Jeju Island.

Recycled aggregate is essential to protect Jeju Island's natural environment, but waste concrete, including porous basalt, is a factor that lowers the quality of recycled aggregate. Therefore, an experiment was conducted to analyze the properties of concrete application of basalt-based recycled aggregate (B-RA) through quality improvement. The absorption of the B-RA ranged from 3-5%; restricting its absorption to less than 3% was challenging owing to its porosity and irregular shape. However, the increase in the solid volume percentage of the concrete when replacing 25 or 50% of fresh basalt aggregate with recycled basalt aggregate improved the mechanical performance of the concrete, especially at 25%, for which a compressive strength of 55.9 MPa and modulus of elasticity of 25.9 GPa exceeded those of concrete with fresh basalt aggregate. Moreover, increasing the replacement ratio of the fresh basalt with recycled aggregate reduced the slump and decreased the air content, consequently increasing the concrete drying shrinkage. However, the replacement of fresh basalt aggregate with recycled basalt aggregate unaltered the mechanical performance of the concrete. The results indicate that efficient use of recycled aggregates can yield superior performance to that of fresh basalt, irrespective of aggregate quality.

Emphysematous myocardial abscess without infective endocarditis.

Diagnosis of myocardial abscess without endocarditis is challenging, and a high index of clinical suspicion is fundamental for diagnosis. It should never be ruled out before TEE. And CT could be a helpful modality in case of emphysematous morphology.

Prognostic implications of the electrocardiographic findings in acute myocarditis: Which is the strongest one?

Myocarditis is an inflammatory disease of the myocardium with high morbidity and mortality; however, definite prognostic factors are still unclear. Therefore, we aimed to evaluate the predictor of clinical outcomes of acute myocarditis focusing on electrocardiographic findings. The overall result of the study consists of a total of 51 patients demonstrated that wide QRS duration is a meaningful factor for predicting the fulminant course of acute myocarditis. This finding may encourage timely mechanical support resulting in better clinical outcomes.

A Phase II Trial of Imatinib Mesylate as Maintenance Therapy for Patients With Newly Diagnosed C-kit-positive Acute Myeloid Leukemia.

INTRODUCTION: Adults with acute myeloid leukemia (AML) have a high rate of remission; however, more than 50% relapse. C-kit is expressed in approximately 60% of patients with de novo AML and represents a potential therapeutic target. MATERIALS AND METHODS: Patients with newly diagnosed AML received 12 months of imatinib mesylate as maintenance therapy after the completion of post-remission therapy. The primary objective was to determine whether this approach improved progression-free survival (defined as no relapse and no death) compared with historical controls. RESULTS: The median progression-free survival of patients < 60 years of age was 52.1 months (historical control, 13 months) and for patients ≥ 60 years of age was 10.7 months (historical control, 8 months). The median level of AF1q expression was high (9.59), and 84% of patients had moderate or high levels of drug-resistance factors. CONCLUSIONS: Imatinib maintenance therapy may improve the outcome of newly diagnosed patients with AML who are < 60 years of age.

Feasibility of right coronary artery first ergonovine provocation test.

BACKGROUND: Intracoronary (IC) provocation angiography is recommended when variant angina is suspected. However, specific procedure-related factors remain uncertain. METHODS: Intracoronary ergonovine infusion was used for the provocation test. About 10, 20, and 40 µg of ergonovine were sequentially injected into the right coronary artery (RCA). During a negative or intermediate response or depending on the clinician's discretion, the left coronary artery (LCA) was injected with incremental doses of 20, 40, and 80 µg of ergonovine or vice versa. If significant coronary spasm or positive clinical findings were noted, the test was stopped immediately and IC nitroglycerine was injected. RESULTS: We reviewed a total of 725 patients (male: 402; mean age: 58.5 years). Spasm-positive response was observed in 269 patients (37.1%), intermediate response in 113 patients (15.6%), and negative response in 343 patients (47.3%). The right radial artery approach was used in most cases (92.6%), and the RCA first approach was mainly chosen (95.0%). The provocation results in the RCA and LCA (93.4%, 381/408) were highly consistent, and the clinically significant discrepancy rate (RCA positive/LCA negative or RCA negative/LCA positive) was 1.5% (6/408). The RCA-alone provocation test can identify spasm-positive response in 93.4% of the patients (228/244). The mean procedure time was 39.9 ± 11.0 min, and approximately 3.3% (24/725) of the patients developed acute complications. CONCLUSIONS: The RCA-first IC ergonovine provocation test is feasible, and the RCA-alone spasm provocation could be acceptable except in an intermediate response, highly clinically suspected cases, or high-risk patients.