Trends in the Incidence of In-Hospital Mortality, Cardiogenic Shock, and Utilization of Mechanical Circulatory Support Devices in Myocarditis (Analysis of National Inpatient Sample Data, 2005-2014).

BACKGROUND: Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients. METHODS: We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged >18 years with myocarditis in the United States. RESULTS: The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend <.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend <.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P< .01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P< .01). CONCLUSION: Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.

In-hospital outcomes of transcatheter mitral valve repair with Mitraclip in patients with pulmonary hypertension: Insights from the National Inpatient Sample.

BACKGROUND: Periprocedural outcomes of transcatheter mitral valve repair (TMVR) with Mitraclip in patients with pulmonary hypertension (PH) are not well studied. METHODS: Patients who underwent TMVR with Mitraclip between 2011 and 2015 were identified using the National Inpatient Sample (NIS). All missing variables were excluded from the analysis and therefore, complete case analysis was performed. RESULTS: A total of 1,037 patients underwent TMVR with Mitraclip between 2011 and 2015. The prevalence of PH in these patients was 32.6%. In-hospital outcomes were compared between PH group and non-PH group. Inpatient mortality after TMVR was similar between the two groups (3.2% vs. 2.1%, OR 1.57, P = 0.335). There was no statistical significance between the two groups in the rates of hemorrhage requiring transfusion (8.5% vs. 7.2%, OR 1.17, P = 0.587), cardiogenic shock (4.4% vs. 4.5%, OR 0.98, P = 0.951), acute respiratory failure (15.2% vs. 13.1%, OR 1.23, P = 0.460), postoperative sepsis (2.75% vs. 3.9%, OR 0.66, P = 0.340), postoperative deep vein thrombosis or pulmonary embolism (2.7% vs. 3.9%, OR 1.98, P = 0.348). In addition, non-routine home discharge, median hospital cost and length of stay were similar between the two groups. CONCLUSION: Pre-existing PH in patients undergoing TMVR with Mitraclip does not adversely affect in-hospital outcomes in this cohort of patients. Therefore, PH does not carry a prohibitive risk in selecting patients for Mitraclip procedure.

Aspirin Resistance: Cardiovascular Risk Game Changer.

BACKGROUND: Aspirin (ASA) is the most used medication on the globe. ASA is a primary pillar of the secondary prevention of cardiovascular atherothromboembolic events. However, a fraction of the population does not respond to ASA as expected in a unique phenomenon called ASA resistance. Multiple mechanisms were described and studied in the literature to explain this phenomenon. AREA OF UNCERTAINTY: ASA resistance is an interesting phenomenon that is worth studying and reviewing. Mechanisms behind this resistance are various and although the rarity of some, it is crucial for the modern health provider to be aware of such phenomenon and its possible explanations to provide more efficient preventive cardiology practice. Our study aimed to review and conclude the evidence behind ASA resistance and its implication on the cardiovascular health. DATA SOURCES: We searched databases like PubMed, EMBASE, Ovid by midline, and Google Scholar for published articles and abstracts. RESULTS: Our systemic search revealed more than 100 articles in relation to ASA resistance. We selected 40 articles, which were relevant for this review. Various mechanisms were described in the literature, with few of them very well documented and understood. Main mechanisms include medication nonadherence, interaction with proton pump inhibitors, esterase-mediated ASA inactivation, post-coronary artery bypass grafting (CABG) MRP-4-mediated ASA consumption, cyclooxygenase-1 (COX-1) polymorphisms, high platelet turnover-associated regeneration of platelet COX-1, and the documented platelet ability of de novo COX-1 synthesis in response to thrombin and fibrinogen. CONCLUSION: Multiple mechanisms of ASA resistance were described in the literature. Awareness of such interaction is important for medical practitioners. Bottom line, further studies and reviews are needed to further study this phenomenon and its implication on the cardiovascular health and hence reaching a valid evidence-based conclusion that might change the practice and improve the patient preventive health care.

The impact of atrial fibrillation on transcatheter mitral valve repair outcomes: A propensity-matched analysis.

BACKGROUND: The concomitant presence of atrial fibrillation (AF) in the setting of Transcatheter Mitral Valve Repair (TMVR) represents a clinical challenge. Despite the high AF burden in patients presenting for the TMVR procedure, there are no studies that evaluate the impact of AF on in-hospital outcomes of TMVR in a nationally representative United States sample reflecting real practice. Therefore, we sought to study the outcomes of AF patients undergoing TMVR. METHODS AND RESULTS: The study included 1026 patients from the National Inpatient Sample (NIS) registry. Patients (age ≥18 years) who had undergone TAVR as a primary procedure from 2011 to 2014 were included, using the ICD-9-CM diagnostic codes. We examined patient characteristics and in-hospital outcomes. To account for patient and hospital-level baseline differences, we performed propensity score-matched analysis. The prevalence of AF was approximately 56%. After adjusting for patient-level and hospital-level characteristics, there was no statistical difference regarding in-hospital mortality (odds ratio [OR] 0.72, 95%CI 0.29-1.80, P = 0.487), post-TMVR complications, length of stay (OR 1.15, 95%CI 0.97-1.38, P = 0.111), and cost of hospitalization (OR 1.04, 95%CI 0.94-1.14, P = 0.475) between the group with AF versus without AF. However, patients with AF were more likely to have non-routine hospital discharge (42.94% vs 35.48% P = 0.02). CONCLUSION: AF is a frequently encountered arrhythmia among patients undergoing TMVR with MitraClip. However, TMVR can be performed safely in the vast majority of patients, irrespective of their baseline rhythm.

Diltiazem-Associated Cardiogenic Shock in Thyrotoxic Crisis.

CLINICAL FEATURES: The patient we present is a 39-year-old woman with a history of hyperthyroidism who developed fast atrial fibrillation secondary to thyrotoxic storm. After the initiation of intravenous diltiazem drip, she developed hypotension, bradycardia, then asystole cardiac arrest. THERAPEUTIC CHALLENGE: It is well known that calcium channel blockers and beta blockers should be used with extreme caution if the patient with thyroid storm has decompensated heart failure with reduced ejection fraction. Despite this, it is recognized that guidelines for the management of thyroid storm do not include an algorithm of action in this situation. Thus, dealing with low-output failure during thyroid storm may pose a critical challenge. SOLUTION: A significant portion of patients with thyrotoxic storm have an underlying low-output cardiac failure. Early identification, proper hemodynamic monitoring, and administration of the agents with appropriate pharmacodynamic profile and therapeutic potentials are essential to avoid treatment-induced cardiogenic shock.

The Impact of COVID-19 on Radiological Science Students and Interns at King Saud bin Abdulaziz University for Health Sciences: Cross-Sectional Study.

Introduction: The impact of the coronavirus disease (COVID-19) outbreak on many parts of our lives cannot be overstated. This study aimed to identify the psychological, physical activity, and educational effects of COVID-19 on radiological sciences students and interns at the three campuses of King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Jeddah, and Alahsa. Methods: A cross-sectional study was conducted between November and December 2021 among Saudi-108 radiological sciences students and interns using non-probability convenient sampling at King Saud bin Abdul-Aziz University for Health Science (KSAU-HS), Riyadh, Jeddah, and Alahsa using a validated questionnaire. Statistical analyses were conducted using Excel and JMP statistical software. Results: 102 out of 108 completed the questionnaire resulting in a 94.44% response rate. The percentage of the overall negative psychological impact was 62%. For the physical activity effects of COVID-19 among students and interns, 96% reported a decline in their physical activities. 77% of participants reported a fair impression that the students were able to achieve some of their academic goals and acquired new skills during the pandemic, and 20% reported a good impression. They achieved all their goals and developed new skills, whereas 3% reported bad impressions and needed to achieve their goals or improve their skills. Conclusion: COVID-19 had a negative psychological and physical activity impact on RADs students and interns at the three KSAU-HS campuses in the Kingdom of Saudi Arabia. Despite technical difficulties, students and interns reported positive academic outcomes from COVID-19.

Coronary Intra-orbital Atherectomy Complications and Procedural Failure: Insight From the Manufacturer and User Facility Device Experience (MAUDE) Database.

BACKGROUND: The Diamondback 360® Coronary Orbital Atherectomy System (Cardiovascular Systems Inc., St. Paul, MN) is the first and only orbital atherectomy system approved by the US FDA for the treatment of severely calcified lesions. While the device has proven to be safe in clinical trials, real-world data are minimal. METHODS: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports on the Diamondback 360® Coronary from January 2019 to January 2022. RESULTS: A total of 566 events were reported during the study period. After the exclusion of duplicate reports, the final cohort included 547 reports. The most common mode of failure was break or separation of a device part (40.4%, n = 221) mainly due to breaking in the tip of the ViperWire (66.1%), driveshaft (22.7%), or crown (12.2%). The most common vessel associated with events was the left anterior descending artery (31.4%), followed by the right coronary artery (26.9%), left circumflex (21.6%), and left main coronary artery (6.4%). The most common clinical adverse outcome was perforation (33.0%, n = 181) with 23.7% resulting in cardiac tamponade. Most perforation cases were treated by covered stent (44.2%), surgery (30.5%), stent (98%), and balloon angioplasty (9%). There were 89 (16.3%) events of death with 67% due to perforation (p < 0.001). CONCLUSION: Our study provided a glimpse of real-world adverse outcomes and common modes of failure due to orbital atherectomy. The most common mode of failure was the break or separation of a device part and the most common complication was perforation according to the MAUDE database. It will help physicians to anticipate complications and escalate care appropriately.

Balloon Expandable Transcatheter Aortic Valve Implantation in Failing Self-Expandable Transcatheter Valve in Degenerated Surgical Bioprosthesis: Valve-in-Valve-in-Valve Implantation for the Treatment of Early Degenerative Prosthetic Insufficiency.

Background: Transcatheter aortic valve implantation (TAVI) has emerged as the standard of care for patients with severe aortic stenosis who are at high surgical risk. However, transcatheter valves can degenerate, and redo TAVI has been reported after surgical aortic valve implantation and post initial TAVI. Case Report: We describe the case of a 70-year-old male who presented with decompensated heart failure secondary to severe prosthetic valve insufficiency. The patient had a history of distant triple coronary artery bypass surgery in 2004, surgical ascending aortic aneurysm repair and stentless aortic valve replacement in 2012, and transcatheter CoreValve (Medtronic) implantation in 2015 for the failing stentless aortic valve. In 2019, the patient presented with heart failure symptoms. A 29-mm SAPIEN 3 valve (Edwards Lifesciences) was implanted for the third time (valve-in-valve-in-valve) with excellent clinical and echocardiographic results and no evidence of coronary obstruction. Conclusion: Early (<5 years) bioprosthetic valve insufficiency after initial valve-in-valve implantation can be successfully treated with a second TAVI.

Incidental Gonadal Vein Thrombosis Diagnosed Using Computed Tomography Imaging: A Single-Center, Retrospective, Cohort Study.

Objectives Gonadal vein thrombosis is an uncommon but serious condition that can be fatal if it goes unnoticed. Up to 80% of cases occur in patients after delivery, hysterectomy, or lymphadenectomy for gynecological neoplasms. The objective of this study was to determine the incidence of gonadal vein thrombosis using computed tomography (CT) imaging at our center and to describe associated risk factors. Methods A retrospective, single-center, observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. Data were collected for all patients diagnosed with incidental gonadal-vein-thrombosis using contrast-enhanced computed tomography imaging of the abdomen and pelvis between January 2005 and December 2017. We included all patients with incidental findings of gonadal vein thrombosis and excluded those with incomplete data. Results In total, 58/68,268 (0.08%) patients were included. Fifty-seven patients were females, and only one was male. The mean age (years) of the patients was 50.0±15.0 (range 4-87). Thirty-four patients (59%) had right gonadal vein thrombosis, 20 (34%) had thrombosis on the left side, and four (7%) had bilateral thrombosis. Nineteen patients (33%) had undergone pelvic surgery previously. Forty-four patients (76%) had a malignancy at the time of diagnosis. Forty-two patients (72%) were treated with anticoagulants after the diagnosis. Conclusion Gonadal vein thrombosis is a rare clinical entity with vague clinical presentation. The incidence in the oncology population is similar to the reported incidence in the obstetric population. Initiation of anticoagulation therapy is important to treat this condition and limit complications.

Methadone-Induced Polymorphic Ventricular Tachycardia Complicated by Takotsubo Cardiomyopathy in a Malnourished Patient.

Takotsubo cardiomyopathy (TC) is a syndrome characterized by acute and transient regional systolic myocardial dysfunction. TC often mimics myocardial infarction without obstructive coronary disease. We present a case of a 48-year-old woman who developed TC following the onset of polymorphic ventricular tachycardia in the setting of methadone intoxication.

Esophago-Pericardial Fistulae as a Sequela of Boerhaave Syndrome and Esophageal Stenting: A Case Report and Review of Literature.

Esophago-pericardial fistulae is a rare and dreaded entity. Most reported cases in the literature were described in association with advanced upper gastrointestinal malignancies, prior surgical procedures, and radiofrequency atrial fibrillation ablation. It has been rarely reported in association with benign esophageal conditions. Surgery had been the mainstay of treatment, but there are increasingly reported cases treated successfully with esophageal stenting and pericardial drainage. In this article, we report a novel case of an esophago-pericardial fistulae occurring as a sequela of esophageal stent placed for the management of Boerhaave syndrome.

Severe Sinus Bradycardia: An Unusual Cardiac Manifestation of COVID-19.

There has been an accumulating evidence of association between COVID-19 (coronavirus disease 2019) infection and cardiovascular complications. We describe a case of a 58-year-old lady with a history of systolic heart failure and COVID-19 infection, who developed persistent symptomatic bradycardia, requiring pacemaker placement as unusual conductive tissue involvement of this novel coronavirus.

Patient-Based Dose Audit for Common Radiographic Examinations With Digital Radiology Systems: A Retrospective Cross-Sectional Study.

This study aims to audit radiation doses of adult patients who underwent common diagnostic X-ray examinations and compare dose area product (DAP) values with the established International Diagnostic Reference Level (IDRLs). Retrospective cross-sectional records of 339-patients who underwent 699-radiographic examinations between October 2018 and March 2019 were obtained. Patient-related factors, exposure, and DAP data were recorded for the six most common examinations. The mean and 75th percentile of DAPs were recorded and compared to IDRLs values. The 75th percentiles of the locally measured DAPs were below IDRLs for all examinations except for lateral lumbar, AP, and lateral thoracic spine, in which DAP-75th-percentile exceeded all IDRLs by up to 40.7%, 2.8%, 365.5%, respectively. Considering the type of detector used, the mean of the locally measured DAPs significantly exceeded the UK DRLs for the lateral thoracic spine and lateral lumbar spine. Locally measured DAP values were below the IDRLs except for thoracic and lumbar spine projections, which significantly exceeded.

Percutaneous coronary intervention following Fontan procedure.

Fontan procedure is known to increase the risk of thromboembolic events. However, coronary artery thrombotic occlusion is rarely reported in patients with Fontan procedure. We present a case of a 10-year-old boy with hypoplastic left heart syndrome palliated with a Fontan procedure who presented with myocardial infarction secondary to thrombotic occlusion of the left circumflex coronary artery. He underwent successful percutaneous coronary intervention with thrombus aspiration, balloon angioplasty, and stent placement, highlighting the necessity of collaboration between congenital and adult cardiologists to treat acute coronary syndrome among this challenging young population.

Modified CHA2DS2-VASc score predicts in-hospital mortality and procedural complications in acute coronary syndrome treated with percutaneous coronary intervention.

BACKGROUND: Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA2DS2-VASc score, comprised of easily accessible clinical factors in predicting adverse events. METHODS: The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA2DS2-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost. RESULTS: There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH3A2DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH3A2DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH3A2DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82-0.84). Stepwise increases in CH3A2DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96-2.03) p < 0.001) and all secondary outcomes. CONCLUSION: This study supports the applicability of the CH3A2DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.