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.

Association polymorphism of guanine nucleotide-binding protein ß3 subunit (GNB3) C825T and insertion/deletion of the angiotensin-converting enzyme (ACE) gene with peripartum cardiomyopathy.

Introduction: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-related heart disease. Genetic roles such as gene polymorphisms may relate to the etiology of PPCM. This study analyzes the association between single nucleotide gene polymorphism (SNP) guanine nucleotide-binding protein beta-3 subunit (GNB3) C825T and insertion/deletion (I/D) of the angiotensin-converting enzyme (ACE) gene with the incidence of PPCM. Methods: An analytic observational study with a case-control design was conducted at the Integrated Cardiac Service Center of Dr. Soetomo General Hospital, Surabaya, Indonesia. PPCM patients of the case and control groups were enrolled. Baseline characteristic data were collected and blood samples were analyzed for SNP in the GNB3 C825T gene and for I/D in the ACE gene by using the polymerase chain reaction, restriction fragment length polymorphism, and Sanger sequencing. We also assessed ACE levels among different ACE genotypes using a sandwich-ELISA test. Results: A total of 100 patients were included in this study, with 34 PPCM cases and 66 controls. There were significant differences in GNB3 TT and TC genotypes in the case group compared with that in the control group (TT: 35.3% vs. 10.6%, p = 0.003; TC: 41.2% vs. 62.5%, p = 0.022). The TT genotype increased the risk of PPCM by 4.6-fold. There was also a significant difference in the ACE DD genotype in the case group compared with that in the control group (26.5% vs. 9.1%, p = 0.021). DD genotypes increased the risk of PPCM by 3.6-fold. ACE levels were significantly higher in the DD genotype group than in the ID and II genotype groups (4,356.88 ± 232.44 pg/mL vs. 3,980.91 ± 77.79 pg/mL vs. 3,679.94 ± 325.77 pg/mL, p < 0.001). Conclusion: The TT genotype of GNB3 and the DD genotype of the ACE are likely to increase the risk of PPCM. Therefore, these polymorphisms may be predisposing risk factors for PPCM incidence. ACE levels were significantly higher in the DD genotype group, which certainly had clinical implications for the management of PPCM patients in the administration of ACE inhibitors as one of the therapy options.

The anatomical snuffbox for transradial access in arteriovenous fistula intervention: Case report and brief review of the literature.

Left distal transradial artery (dTRA) access in the anatomical snuffbox is a relatively novel technique and is considered beneficial when left TRA access is required. This technique offers essential advantages, including improved patient comfort and lower vascular complications. dTRA may provide an entry site for retrograde recanalization of the radial artery. We presented a case of a 65-year-old man with 5-stage chronic kidney disease (CKD) and had left a radio-cephalic arteriovenous fistula (AVF) for routine hemodialysis. There was obstruction of AVF a month after creation. The vascular intervention has been performed using left dTRA access for retrograde recanalization. Angiogram showed cephalic vein obstruction and non-significant stenosis of the proximal radial artery. Percutaneous transluminal angioplasty was successful in improving cephalic vein flow. Hemostatic performed without a hemostatic device. This case report highlights the dTRA access approach in the anatomical snuffbox to recanalize AVF occlusion in the wrist in a patient with CKD.

Recognizing dialysis access steal syndrome with central vein stenosis as arteriovenous fistula complication: A case report.

INTRODUCTION: Ischemic consequences of hemodialysis arteriovenous (AV) access are infrequent, yet they can cause substantial limb impairment or even loss. Ischemia can be caused by many factors, but the most common etiology is reduced blood supply to the distal extremities due to blood flow through the AV fistula (AVF) or AV graft. We reported a case of dialysis access steal syndrome (DASS) in a diabetes mellitus patient. CASE REPORT: A 69-year-old diabetic man with left brachiocephalic AVF on his left upper arm has main complaint of left-hand pain, swelling, and coldness. There are also trophic darkening changes in the distal first, third, and fourth fingers. A duplex doppler examination revealed a normal functional AV shunt with bidirectional distal retrograde inflow. There was also significant stenosis at axillary vein. So, a diagnosis of DASS with suspicion of distal anastomosis stenosis at axillary vein was made. The patient underwent digital amputation and surgical plication of the AV shunt. He also underwent percutaneous transluminal angioplasty at the level of axillary. After 10 days of care, he was later discharged. CLINICAL DISCUSSION: DASS is life and limb-threatening clinical disorder. Not only does the discomfort make it difficult for the patient to tolerate hemodialysis, but the ischemia can cause tissue necrosis and the eventual loss of fingers and possibly the patient's life. Doppler ultrasonography is a non-invasive technique that provides important information about vascular anatomy and hemodynamics. Aggressive treatment, including limb surgery and intensive blood glucose regulation, will result in favourable results. CONCLUSIONS: DASS is a rare condition usually encountered in hemodialysis patients with AVF. Proper diagnosis and management are needed to get an optimal outcome for the patient.

The physiological insight of Coenzyme-Q10 administration in preventing the incidence of reperfusion arrhythmia among patients undergoing coronary artery bypass grafting surgery.

Reperfusion arrhythmia following cardiac surgery has long been studied as part of myocardial damage. Reperfusion injury is thought to be exacerbated by oxygen-free radicals, whereas arrhythmogenic oscillations in membrane potential are mediated by reactive oxygen. Coenzyme Q10 is a lipid-soluble antioxidant that inhibits lipid peroxidation in biological membranes and supplies ATP cell synthesis, required as the organism's primary energy source. This process explains how Coenzyme Q10 helps stabilize membranes and avoids critical metabolite depletion that may relate to reperfusion arrhythmia. There is a reduction of iatrogenic Coenzyme Q10 after coronary artery bypass surgery (CABG). On the other hand, there is an increased inflammatory process and cellular demand post CABG procedure. It leads to ischemia that can be manifested as arrhythmia. Reperfusion arrhythmia was less common in patients who took Coenzyme Q10. These findings suggest that Coenzyme Q10 supplementation might help patients with heart surgery avoid reperfusion arrhythmia. However, a higher-quality randomized controlled study is needed to determine the effect of Coenzyme Q10 in preventing reperfusion arrhythmia in cardiac surgery patients.

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.

NSTEMI with total left circumflex occlusion: how the N-wave might help (case report).

A rise and/or fall in troponin level is an indication of type 1 or 2 myocardial infarct. A 62-year-old male physician presented to emergency room with chest discomfort followed by thought to be normal electrocardiogram (ECG) and normal echocardiography results. His serial hs-troponin test showed remarkable escalation three hours from the initial (107 ng/l into 4.978 ng/l), suggesting a high-risk non-ST-segment myocardial infarction (NSTEMI). An early invasive procedure was performed, showing acute total occlusion (TO) in the obtuse marginal 1 branch. We retrospectively reviewed our examination to diagnose better the presence of TO in NSTEMI patients presented with non-diagnostic examination. Our evaluation showed a minor change in the form of an 'N-wave' pattern on the ECG, which was not yet an established guideline criterion for prompt angiography. Although ECG pattern is often normal in LCx occlusion, recent study shows the presence of 'N-wave' ECG pattern in 10% of NSTEMI cases following TO at LCx.

Case Report: Heparin-induced thrombocytopenia during COVID-19 outbreak: the importance of scoring system in differentiating with sepsis-induced coagulopathy.

Background: COVID-19 disease is accompanied by derangement of coagulation with a risk of fatal thromboembolic formation. COVID-19 patients are among those indicative for heparin treatment. Increased heparin administration among COVID-19 patients increased heparin induced-thrombocytopenia's risk with/without thrombocytopenia. Case presentation: We present a 71-year-old male patient who came to the emergency room (ER) with a COVID-19 clinical manifestation followed by positive PCR nasopharyngeal swab result. He was assessed to have acute respiratory distress syndrome (ARDS), as shown by rapid progression of hypoxemic respiratory failure and bilateral pulmonary infiltrate. He was then treated with moxifloxacin, remdesivir, dexamethasone, unfractionated heparin (UFH) pump, and multivitamins. During admission, his respiratory symptoms got worse, so he transferred to the ICU for NIV support. On the ninth day of admission, he had gross hematuria followed by a rapid fall of platelet count. We used two different scoring systems (4Ts and HEP scoring system) to confirm the diagnosis of heparin-induced thrombocytopenia (HIT). Following the discontinuation of UFH injection, the thrombocyte continued to rise, and hematuria disappeared. Conclusion: Heparin-induced thrombocytopenia is associated with an increased risk of severe disease and mortality among COVID-19 patients. The differential diagnosis of HIT could be difficult as thrombocytopenia can also be caused by the progression of infection. We use two scoring systems (4Ts and HEP scoring) in order to help us managing the patient. These could improve the outcomes, thus avoiding morbidity and mortality.