Left Atrial Appendage Closure in a Patient With a Patent Foramen Ovale Septal Occluder Device.

Left atrial appendage closure (LAAC) has evolved as a safe alternative to oral anticoagulation therapy for stroke prophylaxis. However, the presence of a patent foramen ovale (PFO) occluder device is considered a relative contraindication. Here we report a successful case of LAAC in the presence of a PFO occluder device. (Level of Difficulty: Beginner.).

Massive purulent pericarditis presenting as cardiac tamponade.

Acute bacterial pericarditis is rarely encountered in the modern antibiotic era. Purulent pericarditis is a serious form of bacterial pericarditis with high mortality. It can rapidly progress to cardiac tamponade, leading to hemodynamic instability, septic shock, and death if left untreated. Here we present a case of massive purulent pericarditis with cardiac tamponade that was successfully managed with intravenous antibiotics and drainage in a young immunocompetent man.

An Atypical Cardiac Manifestation of Fabry Disease from a Novel Pathological Variant on the GLA Gene.

Fabry disease (FD) is one of the most common lysosomal storage disorders and is caused by an X-linked progressive inborn error of metabolism in the alpha-galactosidase A (α-Gal A) gene. This leads to intracellular accumulation of glycosphingolipids, mainly globotriaosylceramide (Gb3), throughout the body. The impact of this accumulation is seen across multiple cell lines and therefore can cause multisystem organ dysfunction. The phenotype of FD results from variants on the GLA gene which codes for α-Gal A production, and variants on this gene have been shown to be strongly related to unexplained or idiopathic cardiovascular disorders. This report describes a 36-year-old Caucasian male found to have left ventricular hypertrophy (LVH) followed by genetic testing because of his family history of sudden cardiac death which revealed a variant of unknown significance for the GLA gene. Further measurement of α-Gal A leukocyte activity showed low levels, which was diagnostic for FD. The index patient had an unusual non-classic phenotype in that his sole presenting symptom was asymptomatic LVH, he presented early, and had low α-Gal A leukocyte activity. Early detection and prompt treatment with enzyme replacement therapy can improve outcomes and decrease mortality. In the absence of known risk factors, non-classical FD should be strongly considered in patients with unexplained LVH and a family history of sudden cardiac death at a young age.

Left Ventricular Thrombus After Acute Decompensated Heart Failure in the Setting of Ischemic Cardiomyopathy.

A 70-year-old male with a medical history significant for long-standing ischemic cardiomyopathy (ICM) and heart failure with reduced ejection fraction (HFrEF) was admitted to the hospital with shortness of breath (SOB) five days after an acute heart failure (HF) exacerbation. He had non-radiating chest pressure now at rest, but without evidence of an acute coronary syndrome (ACS). Diagnostic work-up on readmission included a transthoracic echocardiogram (TTE), which revealed worsening left ventricular (LV) systolic dysfunction with new wall motion abnormalities and an incidental echo density in the LV apex, suggestive of an LV thrombus. These findings were unseen on imaging 20 months prior. The patient was initiated on warfarin to be maintained for three months, and discharged in stable condition after optimization of his anginal symptoms. Cardiac catheterization was not attempted secondary to the patient's chronic kidney disease (CKD). The incidental finding of an LV thrombus occurred despite compliance with guideline-directed medical therapy of HFrEF and ICM, including adjunctive use of clopidogrel. With the poor survival associated with thromboembolism, the prevention, risk stratification and appropriate therapeutic approach to LV thrombus are poorly delineated in patients with HFrEF in sinus rhythm. Currently, the screening guidelines for the identification of LV thrombus in patients with HFrEF are also unknown. Given mixed evidence regarding prophylactic anticoagulation, we present this case of an incidental LV thrombus found during an episode of acute decompensated HF in the setting of long-standing ICM to emphasize the need to suspect LV thrombus formation after such presentations with closer follow-up for prompt detection and timely treatment.

A Rare Case of Traumatic Coronary Artery Dissection After a Motor Vehicle Collision.

Coronary artery dissection is a rare and life-threatening condition. It can result in thrombus formation and coronary occlusion with subsequent acute coronary syndrome, ventricular arrhythmia, and death. Traumatic coronary artery dissection is an especially rare type of dissection and usually happens in the setting of a high-speed motor vehicle collision. Early recognition and treatment are crucial for survival in patients suffering from this pathology. We present a case of a patient who developed right coronary artery dissection following a motor vehicle collision that was subsequently managed by coronary angiogram and revascularization.

A Case of Amitriptyline-induced Myocarditis.

Amitriptyline is a widely prescribed tricyclic antidepressant (TCA) with a very concerning cardiotoxicity profile, but it is one that has not been discussed much in literature. Here, we present a case of amitriptyline toxicity presenting as myocarditis with pericardial involvement. A 21-year-old male with no previous cardiac history presented to the emergency department (ED) with a decreased level of consciousness after an amitriptyline overdose as a suicidal attempt. For concerns with airway protection, the patient was intubated and subsequently admitted to the intensive care unit (ICU). An electrocardiogram (EKG) showed sinus tachycardia, prolonged QRS complex, prolonged QTc interval, and nonspecific ST-T wave changes. Intravenous fluid resuscitation and sodium bicarbonate were administered with a target blood pH of 7.5 to 7.55. Two days later, the patient was taken off mechanical ventilation and improved clinically. However, troponin levels began to rise with a peak level of 4.08 µg/L. He then began having fevers, elevated white blood cell counts (WBCs), and elevated inflammatory markers. Transthoracic echo (TTE) revealed an ejection fraction (EF) of 45%-50%, no wall segment motion abnormalities, and a mild-to-moderate pericardial effusion. Cardiac magnetic resonance (CMR) was done, which revealed changes indicative of acute myocarditis, moderate pericardial effusion, a calculated EF of 45% with a moderate left ventricular dilation, and no coronary artery stenosis or anomalous coronary artery origin. Given the patient's age, the absence of cardiac risk factors, and the presence of an amitriptyline overdose along with his EKG, TTE, and CMR findings, we hypothesize that this myocarditis with pericardial involvement is due to amitriptyline-induced direct toxicity.

Meta-analysis of randomized controlled trials on atrial fibrillation ablation in patients with heart failure with reduced ejection fraction.

BACKGROUND: The role of catheter ablation (CA) is increasingly recognized as a reasonable therapeutic option in patients with atrial fibrillation (AF) and heart failure (HF). HYPOTHESIS: We aimed to compare CA to medical therapy in AF patients with HF with reduced ejection fraction (HFrEF). METHODS: We searched the literature for randomized clinical trials comparing CA to medical therapy in this population. RESULTS: Six trials with a total of 775 patients were included. AF was persistent in 95% of patients with a mean duration of 18.5 ± 23 months prior enrollment. The mean age was 62.2 ± 7.8 years, mostly males (83%) with mean left ventricular ejection fraction (LVEF) of 31.2 ± 6.7%. Compared to medical therapy, CA has significantly improved LVEF by 5.9% (Mean difference [MD] 5.93, confidence interval [CI] 3.59-8.27, P < 0.00001, I2 = 87%), quality of life, (MD -9.01, CI -15.56, -2.45, P = 0.007, I2 = 47%), and functional capacity (MD 25.82, CI 5.46-46.18, P = 0.01, I2 = 90%). CA has less HF hospital readmissions (odds ratio [OR] 0.5, CI 0.32-0.78, P = 0.002, I2 = 0%) and death from any cause (OR 0.46, CI 0.29-0.73, P = 0.0009, I2 = 0%). Freedom from AF during follow-up was higher in patients who had CA (OR 24.2, CI 6.94-84.41, P < 0.00001, I2 = 81%. CONCLUSION: CA was superior to medical therapy in patients with AF and HFrEF in terms of symptoms, hemodynamic response, and clinical outcomes by reducing AF burden. However, these findings are applicable to the very specific patients enrolled in these trials.

Meta-analysis of Randomized Controlled Trials on Patent Foramen Ovale Closure Versus Medical Therapy for Secondary Prevention of Cryptogenic Stroke.

The optimal management of patients with cryptogenic stroke (CS) and patent foramen ovale (PFO) remains controversial. We conducted a meta-analysis to assess the effect of PFO closure for secondary prevention of stroke on patients with CS. We searched the literature for randomized control trials assessing the recurrence of stroke after PFO closure compared with medical therapy (antiplatelet and/or anticoagulation). Five randomized control trials with a total of 3,440 patients were included. The mean age was 45.2 ± 9.7 years and follow-up duration ranged from 2.0 to 5.9 years. PFO closure significantly reduced the risk of stroke compared with the medical therapy (2.8% vs 5.8%; relative risk [RR] 0.48, confidence interval [CI] 0.27 to 0.87, p = 0.01, I2 = 56%). The number needed to treat for stroke prevention was 10.5. PFO closure was associated with an increased risk of atrial fibrillation compared with medical therapy (4.2% vs 0.7%; RR 4.55, CI 2.16 to 9.6, p = 0.0001, I2 = 25%). There was no significant difference in all-cause mortality (RR 1.33, CI 0.56 to 3.16, p = 0.52, I2 = 0%), as well as no difference in bleeding risk between the 2 groups (RR 0.94, CI 0.49 to 1.83, p = 0.86, I2 = 29%). In conclusion, our meta-analysis demonstrates that PFO closure is associated with significantly lower risk of recurrent stroke in patients with PFO and CS compared with medical therapy. However, atrial fibrillation was more common among closure patients.

Cardiac Rehabilitation in Patients With Left Ventricular Assist Device: A SYSTEMATIC REVIEW AND META-ANALYSIS.

PURPOSE: Exercise-based cardiac rehabilitation (EBCR) has been demonstrated to improve functional capacity in heart failure (HF). However, there are limited data on the effect of EBCR in patients with advanced HF and left ventricular assist devices (LVADs). This meta-analysis sought to evaluate the effects of EBCR on functional capacity in patients with LVAD. METHODS: PubMed, Web of Science, CINAHL, and Cochrane Library databases were searched for randomized studies assessing the impact of EBCR in patients following LVAD implantation compared with standard therapy (ST). Using pre-defined criteria, appropriate studies were identified and selected. Data from selected studies were extracted in a standardized fashion and a meta-analysis was performed using a random-effects model with DerSimonian Liard weighting. Analysis employed weighted mean difference (WMD) as the effect size and intention-to-treat (ITT) principle. Study quality, publication bias, and heterogeneity were assessed. RESULTS: Six trials with a total of 183 patients (EBCR: 125; ST: 58) were identified. Mean age was 51 years and 83% were males. The initiation of EBCR varied from LVAD implantation during the index hospitalization to 10 mo post-LVAD implantation. The median rehabilitation period ranged from 6 to 10 wk. Exercise-based cardiac rehabilitation was associated with improved peak oxygen uptake ((Equation is included in full-text article.)O2) in all trials. Quantitative analysis was performed on 3 randomized studies involving 61 patients (EBCR = 39, ST = 22). Exercise-based cardiac rehabilitation was associated with significantly greater peak (Equation is included in full-text article.)O2 (WMD: 3.00 mL/kg/min; 95% CI: 0.64-5.35, P = .001). Similarly, 6-minute walk distance (6MWD) showed significantly greater improvement in the EBCR group than in the ST group (WMD: 60.06 m; 95% CI, 22.61-97.50, P = .002). Heterogeneity was low among the included trials. Exclusion sensitivity and per-protocol analysis demonstrated results consistent with ITT analysis. None of the included studies reported serious adverse events related to EBCR, which supports the safety of EBCR after LVAD implantation. CONCLUSION: This systematic review and meta-analysis demonstrated that EBCR following LVAD implantation is associated with greater improvement in functional capacity compared with ST as reflected by improved peak (Equation is included in full-text article.)O2 and 6MWD. However, given the small number of patients, further research into the clinical impact of EBCR in LVAD patients is necessary.

Nonalcoholic fatty liver disease and the risk of clinical cardiovascular events: A systematic review and meta-analysis.

OBJECTIVE: Numerous studies have assessed the association between Nonalcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD). However, results have been conflicting due to variability in definitions of NAFLD and ascertainment of CVD, often combining clinical and surrogate endpoints. We therefore systematically reviewed published literature to assess the association between NAFLD and clinical cardiovascular events (CVE) and performed a meta-analysis. METHODS: We searched PubMed, Medline, Cochrane, CINAHL, and Web of Science databases using terms "nonalcoholic fatty liver disease", "nonalcoholic steatohepatitis", "cardiovascular disease", and their combinations to identify prospective studies published from inception through March 2016. Data from selected studies was extracted and meta-analysis was then performed using random effects model. RESULTS: A total of six studies with 25,837 patients (NAFLD: 5953; controls: 19,884) were included in the final analysis. Patients with NAFLD had a significantly higher risk of clinical CVE compared to controls (RR: 1.77; 95% CI: 1.26-2.48, p<0.001). Exclusion sensitivity analysis did not alter the above results. The association remained consistent for subgroups with clinical coronary artery disease (RR: 2.26; 95% CI: 1.04-4.92, p<0.001) and ischemic stroke (RR: 2.09; 95% CI: 1.46-2.98, p<0.001). The risk of cardiovascular mortality was also increased in the NAFLD group (RR 1.46, 95% CI 1.31-1.64, p<0.001). CONCLUSION: NAFLD patients have a significantly higher risk for clinical CVE compared to those without. These results need to be confirmed in large prospective studies.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Left ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008-2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.

Early versus late surgical intervention or medical management for infective endocarditis: a systematic review and meta-analysis.

OBJECTIVE: Infective endocarditis is associated with high morbidity and mortality and optimal timing for surgical intervention is unclear. We performed a systematic review and meta-analysis to compare early surgical intervention with conservative therapy in patients with infective endocarditis. METHODS: PubMed, Cochrane, EMBASE, CINAHL and Google-scholar databases were searched from January 1960 to April 2015. Randomised controlled trials, retrospective cohorts and prospective observational studies comparing outcomes between early surgery at 20 days or less and conservative management for infective endocarditis were analysed. RESULTS: A total of 21 studies were included. OR of all-cause mortality for early surgery was 0.61 (95% CI 0.50 to 0.74, p<0.001) in unmatched groups and 0.41 (95% CI 0.31 to 0.54, p<0.001) in the propensity-matched groups (matched for baseline variables). For patients who had surgical intervention at 7 days or less, OR of all-cause mortality was 0.61 (95% CI 0.39 to 0.96, p=0.034) and in those who had surgical intervention within 8-20 days, the OR of mortality was 0.64 (95% CI 0.48 to 0.86, p=0.003) compared with conservative management. In propensity-matched groups, the OR of mortality in patients with surgical intervention at 7 days or less was 0.30 (95% CI 0.16 to 0.54, p<0.001) and in the subgroup of patients who underwent surgery between 8 and 20 days was 0.51 (95% CI 0.35 to 0.72, p<0.001). There was no significant difference in in-hospital mortality, embolisation, heart failure and recurrence of endocarditis between the overall unmatched cohorts. CONCLUSION: The results of our meta-analysis suggest that early surgical intervention is associated with significantly lower risk of mortality in patients with infective endocarditis.

Corrigendum to "Acute Amiodarone Pulmonary Toxicity after Drug Holiday: A Case Report and Review of the Literature".

[This corrects the article DOI: 10.1155/2015/927438.].

Fatal Case of Probable Invasive Aspergillosis after Five Years of Heart Transplant: A Case Report and Review of the Literature.

Invasive fungal infections are very common in solid organ transplants and occur most frequently in the first three months after transplant. A 49-year-old female with a history of two remote heart transplants with the most recent one occurring 5 years ago was admitted for increasing shortness of breath, cough, and fever. Computerized tomography (CT) scan of the chest showed left lower lung ground-glass and tree-in-bud opacities. She was started on broad spectrum antibiotics along with ganciclovir and micafungin. Ganciclovir was added due to the patient's past history of CMV infection and empiric fungal coverage with micafungin. Bronchoalveolar lavage (BAL) was performed as her respiratory status worsened and voriconazole was added for possible aspergillosis in combination therapy with micafungin. BAL galactomannan returned positive which was suggestive of aspergillosis. Patient worsened clinically and subsequently succumbed to cardiorespiratory arrest despite our best efforts. It is important to have a high degree of clinical suspicion for invasive aspergillosis in transplant patients even many years after transplant and initiate aggressive therapy due to poor outcomes.

Malignant Course of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case Report and Review of the Literature.

Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.

Probable hydrochlorothiazide-induced myopericarditis: first case reported.

Hydrochlorothiazide has never been reported as a reason for myopericarditis. An African American female, with past history of hypertension, coronary artery disease, and sulfa allergy, presented with indolent onset and retrosternal chest pain which was positional, pleuritic, and unresponsive to sublingual nitroglycerin. Her medications included hydrochlorothiazide (HCTZ) which was started three months ago for uncontrolled hypertension. Significant laboratory parameters included erythrocyte sedimentation rate (ESR) of 47 mm/hr and peak troponin of 0.26 ng/mL. Transthoracic echocardiogram (TTE) revealed preserved ejection fraction with no segmental wall motion abnormalities; however, it showed moderate pericardial effusion without tamponade physiology. We hypothesize that this myopericarditis could be due to HCTZ allergic reaction after all other common etiologies have been ruled out. There is a scarcity of the literature regarding HCTZ as an etiology for pericardial disease, with only one case reported as presumed hydrochlorothiazide-induced pericardial effusion. Management involves discontinuation of HCTZ and starting anti-inflammatory therapy.

Mycotic pseudoaneurysm by vancomycin-intermediate Staphylococcus aureus: a rare cause of persistent bacteraemia.

Pseudoaneurysms are vessel wall ruptures, that are often mistaken for deep vein thrombosis (DVT). A middle-aged man presented with right leg pain, swelling and erythema. His history was significant for persistent Staphylococcus aureus bacteraemia. Ultrasound revealed subacute DVT and laboratory parameters were suggestive of sepsis. He was started on intravenous heparin and antimicrobials. Owing to persistent anaemia despite blood transfusion, MRI of the right thigh was obtained. It revealed a 13×17 cm superficial femoral artery infected mycotic pseudoaneurysm (MPA) with a fresh haematoma. The patient underwent arterial ligation and extensive debridement. Intraoperative cultures revealed daptomycin-resistant vancomycin-intermediate S. aureus (VISA) and he was managed with 6 weeks of intravenous ceftaroline. MPAs are most common in the femoral artery and form <1% of aneurysms. Therapy involves surgical debridement and prolonged antimicrobials. VISA causing MPA is associated with worse outcomes. We report the first time use of ceftaroline in the management of a VISA MPA.