Complex interventions in the failing heart.

PURPOSE OF REVIEW: Heart failure is a complex clinical syndrome with a substantial disease burden. We aim to review the interventional aspects of management of advanced heart failure, focusing on the role of management of coronary artery disease, valvular heart disease, and mechanical circulatory support. RECENT FINDINGS: The patients with coronary artery disease and heart failure requiring revascularization are at higher risk than the rest of the general population. Coronary artery bypass grafting or percutaneous intervention can be used depending on varied patient characteristics and coronary anatomy. Transcatheter aortic valve implantation, Mitraclip and transcatheter ventricular restoration help in tackling the valvular and left ventricular remodeling concerns often seen in this patient population. Temporary hemodynamic circulatory support helps stabilizing patients in cardiogenic shock while long-term support can help bridge them to more definitive therapies. SUMMARY: The management strategies in this disease state are ever evolving with robust evidence coming in support of interventional therapies whenever deemed appropriate. It is the multidisciplinary patient-centered approach, which yields maximum benefit out of these complex interventions.

Non-ischemic Cardiomyopathy: A Rare Adverse Effect of Clozapine.

Clozapine is a dibenzodiazepine antipsychotic used for treatment-resistant schizophrenia. Its association with several side effects such as agranulocytosis, seizure, and insulin resistance is well known. Cardiac side effects such as myocarditis and cardiomyopathy are less common and have been seldom reported. Here we report an unusual case of clozapine-induced nonischemic dilated cardiomyopathy. A 50-year-old female with treatment-resistant schizophrenia on clozapine presented with gradually worsening shortness of breath, productive cough, and pleuritic chest pain. She was found to have non-ischemic dilated cardiomyopathy due to clozapine use as no other causative factor was found. Clozapine was gradually tapered and then discontinued. Repeat echocardiogram in three months revealed improvement in ejection fraction. This case is unique as it outlines clozapine as a rare cause of nonischemic cardiomyopathy, as discontinuation of the drug showed improvement in symptoms and heart function.

An Unusual Presentation of Median Arcuate Ligament Syndrome.

Median arcuate ligament syndrome (MALS) is a rare benign condition typically affecting young females. It usually presents with abdominal symptoms of pain, nausea, and unintentional weight loss. They are usually diagnosed incidentally on CT of the abdomen done for abdominal pain. Here we present a rare case of MALS which presented with an anginal type of chest pain without any abdominal symptoms leading to an extensive workup and incidental diagnosis.

A Case of Left Ventricular Noncompaction Presenting as Atrial Fibrillation.

Ventricular noncompaction is a rare congenital cardiomyopathy resulting from failure in cardiac embryogenesis. Both left and right ventricular involvement has been reported in nature. We present a case of a 69-year-old male presenting with atrial fibrillation complicated with in-hospital cardiac arrest in the setting of left ventricular noncompaction (LVNC). Our case demonstrates the fatal nature of this disease entity thus demanding a high index of suspicion for early detection and treatment.

Pericardial Effusion: Rare Adverse Effect of Clozapine.

Clozapine is a dibenzodiazepine antipsychotic used for resistant schizophrenia, which is known to be associated with side effects such as agranulocytosis, seizures, weight gain, and less commonly myocarditis/ cardiomyopathy. We present a case of a 20-year-old female who presented with chest pain, shortness of breath, and cough. She was later found to have clozapine-induced pericardial effusion that resolved after discontinuation of clozapine therapy. Our case discloses the importance to consider clozapine in the differential diagnosis of pericardial effusion as discontinuation of the drug leads to resolution of effusion, with no need for further treatment.

Slit in the Coronaries: A Case of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a noniatrogenic epicardial coronary artery dissection unrelated to an atherosclerotic disease process. SCAD is responsible for a small percentage of acute coronary syndrome (ACS) cases. The left anterior descending (LAD) artery is the most common artery affected in SCAD, although any coronary artery can be affected. We present an interesting case of SCAD presenting as an ST-elevation myocardial infarction complicated with dissection extending to the left main and distal LAD requiring emergent coronary artery bypass grafting. Our case emphasizes the importance of considering SCAD as a cause for ACS, especially in young patients with minimal atherosclerotic risk factors. Also, a very high recurrence rate demands strict follow-up and multidisciplinary decision making in the population impacted with this rare entity.