Implantable Cardioverter-Defibrillator Placement in Spontaneous Coronary Artery Dissection: A Case Report.

BACKGROUND Spontaneous coronary artery dissection can present with acute coronary syndrome, ventricular arrhythmias, or sudden cardiac death. Implantable cardioverter-defibrillator placement in patients with spontaneous coronary artery dissection is controversial. The purpose of publishing this case is to inform physicians of potential benefits of implantable cardioverter-defibrillator implantation in patients with spontaneous coronary artery dissection. CASE REPORT A 55-year-old woman presented with chest pain, with an electrocardiogram revealing anterior ST-elevation myocardial infarction and troponin peak of 53.8 ng/mL. Coronary angiography revealed mid-left anterior descending artery occlusion, with appearance of spontaneous coronary artery dissection that was not amenable to revascularization. The decision was made to treat medically. In recovery, the patient experienced ventricular fibrillation arrest. The patient was defibrillated once with achievement of return of spontaneous circulation. An Impella CP was placed to stabilize the patient. After the patient was stabilized, an implantable cardioverter-defibrillator was placed. CONCLUSIONS Data on potential benefits of implantable cardioverter-defibrillator placement in patients with spontaneous coronary artery dissection are limited. Most patients with spontaneous coronary artery dissection recover normal coronary architecture; however, there are no guidelines for implantable cardioverter-defibrillator placement in patients with spontaneous coronary artery dissection. Patients with spontaneous coronary artery dissection with high-risk features may benefit from implantable cardioverter-defibrillator for secondary prevention of ventricular arrhythmia and sudden cardiac death, as shown with this case.

The impact of medication-assisted treatment for opioid use disorder on congestive heart failure outcomes.

Congestive heart failure (CHF) and opioid use disorder (OUD) commonly coexist and are major contributors to high healthcare utilization in the United States. Medication assisted treatment (MAT; e.g., buprenorphine and methadone) reduces opioid-related mortality by about 50 %; yet little is known about how OUD treatment impacts CHF outcomes in patients with both CHF and OUD. We examined the impact of MAT (buprenorphine, methadone, and naltrexone) on CHF outcomes in patients diagnosed with OUD and CHF, and which MAT (buprenorphine or methadone) medication is associated with the fewest CHF outcomes. A retrospective cohort study of patients 18 years or older diagnosed with both CHF and OUD was conducted using Optum's de-identified Clinformatics® Data Mart Database. Multivariate logistic regression modeling was used to compared patients who were prescribed MAT to those who were not. The primary outcomes were CHF hospitalizations and CHF emergency department visits. No significant differences in the primary outcomes between the MAT and non-MAT cohorts were observed. In conclusion, the lack of association of MAT with negative CHF outcomes suggest that life-saving MAT can be safely used for OUD treatment in the CHF setting.

Plant Based Diet and Its Effect on Cardiovascular Disease.

Cardiovascular disease remains the leading cause of death globally and here in the United States. Diet has a major impact on the pathogenesis of atherosclerosis and subsequent cardiovascular morbidity and mortality. An unhealthy diet is the most significant potential behavioral and modifiable risk factor for ischemic heart disease. Despite these established facts, dietary interventions are far less frequent than pharmaceutical and procedural interventions in the management of cardiovascular disease. The beneficial effects of a plant-based diet on cardiovascular morbidity and mortality have been demonstrated in a number of recent clinical studies. The significant findings of each study are discussed in this review article, highlighting the role of a healthy plant-based diet in improving cardiovascular outcomes. From a clinician's standpoint, the knowledge and understanding of the facts and data points from these recent clinical studies would ensure more effective patient counseling on the substantial benefits of dietary interventions.

Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database.

Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.

A comparison of Atrial Fibrillation Detection Strategies After Ischemic Stroke-A Retrospective Study.

Objective of this retrospective study was to determine if long-term continuous cardiac monitoring with Implantable loop recorder (ILR) in patients with Cryptogenic strokes or TIA is superior at detecting Atrial Fibrillation (AF) than 30-day Event Monitor (EM) and 48-hour Holter Monitor (HM). Furthermore, we aimed to deduce if uncovering AF leads to lower risk of future ischemic strokes, or reduction in mortality. In 20%-30% cases, the cause of stroke remained unexplained after diagnostic workup which has led to coining of the term, Cryptogenic Stroke (CS). Undiagnosed AF is a prime suspect in CS, but guidelines do not recommend initiation of anticoagulation unless AF has formally been detected. IRB approved retrospective study included patients with at least 1 episode of ischemic stroke or TIA without identifiable cause and was monitored with either HM, EM or ILR to diagnose any undiscovered AF. All patients (n = 531) had at least 1 year, and up to 3 years, of follow-up after device placement. Chi-Squared analysis and Multivariable logistic regression demonstrated no statistically significant difference among 3 devices for detection of AF within 1 month of index stroke but a significant difference in AF detection was observed at 6, 12 and 24 months. Cox proportional hazard model showed device type had no significant impact on secondary outcomes: Subsequent ischemic stroke or TIA, Initiation of anticoagulation, Mortality and Incidence of major bleeding. Despite the superiority of AF detection by ILR, it is not superior to HM or EM in lowering the risk of subsequent stroke or TIA, or in reducing mortality.

Percutaneous Repair of Mitral Regurgitation: A Comprehensive Review of Literature.

Mitral regurgitation is the most common valvular disease in the US and the second most common worldwide. Left untreated, it can lead to the development of heart failure, giving rise to increased mortality rates. Mitral valve intervention is usually indicated in severe mitral regurgitation at the onset of symptoms, even if the function of the left ventricle is preserved. A surgical approach is generally favored according to current guidelines, with excellent clinical outcomes. However, the emergence of novel data from contemporary trials indicates that percutaneous, catheter-based approach may have similar improvements in mortality outcomes while maintaining a superior safety profile when compared to the surgical approach. Here, we discuss transcatheter mitral valve repair as a treatment option for mitral regurgitation and summarize the major clinical trials which were recently conducted on transcatheter repair.

A Case Series of Eustachian Valve Endocarditis: An Under-Diagnosed and Rare Entity.

BACKGROUND The eustachian valve is rarely involved in bacterial endocarditis. Patients who present with bacteremia and evidence of organic septic emboli should raise the suspicion of endocarditis as a possible differential diagnosis. This case series describes 2 unique cases of eustachian valve endocarditis (EVE) in patients who had a history of intravenous drug use; although 63% of EVE is caused by Staphylococcus aureus, the causative agent in our first case was methicillin-resistant Staphylococcus epidermidis (MRSE), which is only the third reported case of EVE caused by Staphylococcus epidermidis. Of note, the previous 2 cases of MRSE EVE were also found to be associated with cardiovascular hardware. CASE REPORT The first case of the series describes EVE by MRSE with an endovascular graft acting as the nidus of infection. Second case of EVE was caused by methicillin-sensitive Staphylococcus epidermidis (MSSA), the source of bacteremia being a rectovesicular abscess. Although initial transthoracic echoes were negative in both cases, subsequent transesophageal echoes were able to detect vegetations on the eustachian valves. Treatment included 4-6 weeks of culture-directed antibiotic therapy for both of our cases. CONCLUSIONS EVE may be an under-diagnosed sequelae of staphylococcal bacteremia, especially in the intravenous drug abuse population, further reinforcing the importance of systemically visualizing all cardiac valves, including the eustachian valves, while performing echocardiography.