Pulmonary arterial hypertension and COVID-19: Piecing the puzzle.

COVID-19 remains a health care concern despite the end of the pandemic. Patients with cardiovascular disease (CVD) are at a higher risk for developing severe COVID-19 complications. Studies investigating the COVID-19 clinical characteristics in pulmonary arterial hypertension (PAH) patients have reported discordant conclusions so far. In this review, we summarize the literature pertaining to the clinical presentation of COVID-19 in patients with PAH. In addition, we discuss common pathological aspects and disease mechanisms between PAH and COVID-19. We present an overview of the different types of PAH-approved therapy and their potential utilization as a treatment in the context of COVID-19. Moreover, we summarize the clinical trials that assessed the safety and efficiency of PAH-approved drugs in COVID-19 patients. Finally, we conclude with proposals for prospective research studies.

Eosinophilic Myocarditis: A Challenging Diagnosis.

Eosinophilic myocarditis (EM) is a rare subtype of myocarditis that is characterized by eosinophilic infiltration of the myocardium and is associated with peripheral eosinophilia in most cases. The diagnosis is suspected in the presence of acute myocarditis and peripheral eosinophilia and is usually confirmed by endomyocardial biopsy (EMB) before starting steroid therapy. Here, we present a case of severe idiopathic eosinophilic myocarditis in a young man with a history of asthma and peripheral eosinophilia. He was treated with high-dose steroids despite negative EMB, and we noted a dramatic improvement in cardiac function. Our case highlights the importance of cardiac magnetic resonance (CMR) and clinical judgment in establishing the diagnosis of EM irrespective of the histopathologic result.

Low dose peripheral systemic thrombolysis for treatment of intermediate-high risk acute pulmonary embolism: a case series.

Background: The management of intermediate-high-risk acute pulmonary embolism (PE) is controversial with increasing interest in more aggressive treatment approaches than anticoagulation alone. Case summary: We describe the case series of four consecutive patients who presented to emergency room for acute shortness of breath. They were diagnosed with intermediate-high-risk acute PE based on the computed tomography pulmonary angiography and transthoracic echocardiography (TTE) findings and the elevated simplified PE score index. They received bolus of 5 mg thrombolytics recombinant tissue plasminogen activator (rtPA) administered through peripheral intravenous (i.v.) line followed by continuous infusion at a rate of 2 mg/h along with unfractionated heparin (UFH) at a rate of 500 mg/h for additional ≤10 h. There after the dose of UFH was increased to reach a therapeutic level. Rapid clinical improvement and also improvement in TTE parameters were noted at discharge. Patients were discharged home on oral anticoagulation. Discussion: Intermediate-high-risk acute PE carries increased risk of mortality and morbidities. Catheter-directed thrombolysis uses a low rtPA dose for local thrombolysis and is associated with low bleeding risk; however it is expensive and requires expertise and human resources. Low-dose rtPA through a peripheral i.v. line might be safe and effective in the treatment of patient with intermediate-high-risk acute PE. This therapeutic approach is readily available at most medical centres, can be started in the emergency room (ER), and can be alternative to catheter-directed thrombolysis nowadays during the COVID-19 era and in hospitals at the periphery and with limited resources.

High Output Heart Failure Secondary to Aorto-Caval Fistula Treated With an Amplatzer Septal Occluder: Case Report and Review of Literature.

Aorto-caval fistula (ACF) is a rare cause of high output heart failure (HOHF). 80 % of cases are due to ruptured abdominal aortic aneurysm, while 10 to 20% are traumatic or congenital. Early diagnosis and treatment are crucial in order to prevent the progression to HOHF. Open surgical repair has been the mainstay therapy of arterio-venous fistulas including aorto-caval fistula; however endovascular approach has become an evolving therapeutic option in the last 20 years. Here, we present a case of high output heart failure secondary to traumatic aorto-caval fistula due to shrapnel injury to the abdomen. Our patient was managed with endovascular approach by the deployment of amplatzer septal occluder that excluded completely the fistula, resulting in the progressive improvement of HOHF. In this manuscript, we review etiologies of high output heart failure and summarize cases of aorto-caval fistula treated with amplatzer septal occluder reported in literature. We also highlight the importance of this endovascular device in the presence of metallic foreign body in the aorta.

Dual antiplatelet therapy up to the time of non-elective coronary artery bypass grafting with prophylactic platelet transfusion: is it safe?

BACKGROUND: Guidelines suggest that patients discontinue Clopidogrel at least 5 days prior to coronary artery bypass grafting (CABG). Those with acute coronary syndrome (ACS) are at high risk for myocardial infarction (MI) if not treated with dual antiplatelet therapy (DAPT). We sought to assess pre and post-operative outcomes of patients maintained on Clopidogrel and aspirin up to the time of surgery and compare them with those on aspirin alone. METHODS: From the cardiac surgery database, 240 patients were retrospectively registered between January and May 2017. There were 126 patients with ACS who underwent CABG on DAPT (Clopidogrel group [CG]) and 114 patients who underwent elective CABG on aspirin alone (control). The CG received intraoperative prophylactic platelet transfusion (PPT). Demographics, comorbidities, and laboratory data were prospectively entered at the time of surgery and were subsequently retrieved for analysis. Per and postoperative findings were identified and compared between both groups. RESULTS: The cohort consisted of 240 patients (mean age 61 years, 81.3% were male, SD ± 9.58). Patients in the CG were younger (Median 57 vs. 63, P-value 0.001), and with male predominance (86% versus 75%, P-value 0.028). In addition, they had less prevalence for diabetes and renal failure as compared to control (P-values 0.003, and 0.005, respectively). There were no significant differences between both groups in number of vessels grafts, duration of on-pump and aortic clamp. Hematologic laboratory data had also similar baseline values. The CG had similar bleeding rate, redo surgery and in-hospital death (P-values non-significant), however more infection and total hospital stay as compared to control (p-values 0.048 and 0.001). CONCLUSION: Patients who are at increased risk for MI can be maintained on DAPT up to the time of CABG because surgery is safe when patients are offered PPT.

Noninvasive Monitoring of Cardiac Output: A Useful Tool Yet?

BACKGROUND AND AIM: End-stage heart failure (HF) patients are at high risk for mortality and morbidity. We aimed to study the role of cardiac output (CO) assessed by Doppler as a noninvasive tool, to predict mortality, rehospitalization rate, and left ventricular assist device (LVAD) implantation at 6 months. METHODS AND RESULTS: We retrospectively analyzed the data of 60 patients with end-stage HF from different etiologies and an LV ejection fraction ≤20%. Patients were divided into two groups, according to the cardiac index (CI) measured by cardiac ultrasound and Doppler - Group 1: low CO or CI <2 l/min/m2 and Group 2: preserved CO or CI ≥2 l/min/m2. Group 1 included 30 patients with mean CI of 1.52 ± l/min/m2. Group 2 included 30 patients with mean CI of 2.27 ± l/min/m2. At 6 months of follow-up, mortality was significantly higher in Group 1 compared to Group 2 (16% vs. 5%, P = 0.0001). Patients in Group 1 had higher hospitalization rate at 6 months compared to patients in Group 2 (3.5 ± 0.9 vs. 1.9 ± 0.6, P = 0.013). There was significantly more LVAD implantation in 16 patients (26%) in Group 1 versus seven patients (12%) in Group 2 (P = 0.04). CONCLUSION: CI measured noninvasively by cardiac ultrasound is a simple and useful tool in HF patients' risk stratification and in predicting prognosis and outcome.

Free-Floating Right Heart Thrombus with Acute Massive Pulmonary Embolism: A Case Report and Review of the Literature.

Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.