Intramyocardial Inflammation after COVID-19 Vaccination: An Endomyocardial Biopsy-Proven Case Series.

Myocarditis in response to COVID-19 vaccination has been reported since early 2021. In particular, young male individuals have been identified to exhibit an increased risk of myocardial inflammation following the administration of mRNA-based vaccines. Even though the first epidemiological analyses and numerous case reports investigated potential relationships, endomyocardial biopsy (EMB)-proven cases are limited. Here, we present a comprehensive histopathological analysis of EMBs from 15 patients with reduced ejection fraction (LVEF = 30 (14-39)%) and the clinical suspicion of myocarditis following vaccination with Comirnaty® (Pfizer-BioNTech) (n = 11), Vaxzevria® (AstraZenica) (n = 2) and Janssen® (Johnson & Johnson) (n = 2). Immunohistochemical EMB analyses reveal myocardial inflammation in 14 of 15 patients, with the histopathological diagnosis of active myocarditis according the Dallas criteria (n = 2), severe giant cell myocarditis (n = 2) and inflammatory cardiomyopathy (n = 10). Importantly, infectious causes have been excluded in all patients. The SARS-CoV-2 spike protein has been detected sparsely on cardiomyocytes of nine patients, and differential analysis of inflammatory markers such as CD4+ and CD8+ T cells suggests that the inflammatory response triggered by the vaccine may be of autoimmunological origin. Although a definitive causal relationship between COVID-19 vaccination and the occurrence of myocardial inflammation cannot be demonstrated in this study, data suggest a temporal connection. The expression of SARS-CoV-2 spike protein within the heart and the dominance of CD4+ lymphocytic infiltrates indicate an autoimmunological response to the vaccination.

Situs Inversus Totalis: Single-Stage Anatomic Repair of Complex Congenital Heart Disease.

Transposition of the great arteries occurs rarely in patients with mirror image dextrocardia and situs inversus, while the combination with severe coarctation of the descending aorta (CoA) makes the anatomy even more unusual. Therefore, it is not surprising that a case with such unusual and complicated anatomy presents unique problems when a primary definitive correction is attempted. We report a patient with situs inversus totalis and complex congenital heart disease including transposition of the great arteries and severe CoA who underwent successful complete, single-stage, anatomic correction.

Complete heart block complicating the acute phase of respiratory syncytial virus bronchiolitis.

Respiratory syncytial virus is the most common pathogen causing lower respiratory tract infection in infants. In recent years, the importance of extrapulmonary complications and longterm sequelae including those involving the cardiovascular system has become apparent. We report on a 10 month old infant with respiratory syncytial virus bronchiolitis, the acute phase of which was complicated by irreversible complete heart block, which was managed conservatively.

Depressive Symptoms in Patients with Congenital Heart Disease: Incidence and Prognostic Value of Self-Rating Depression Scales.

OBJECTIVE: To determine the presence of depressive symptoms in adolescent and adult patients with CHD and their impact on prognosis, using self-rating depression scales. DESIGN: Prospective study. SETTING: Outpatient clinic of a tertiary center. PATIENTS: Sixty ambulatory adolescent and adult patients admitted at the outpatient clinic for regular evaluation. METHODS: Self-rating depression questionnaires (Beck Depression Inventory [BDI] and Zung Self-Rating Depression Scale [Zung SDS]) were administered on admission. Patients were characterized as having depressive symptoms when scores on both questionnaires were above cutoff levels and were subsequently followed for 5.1 ± 1.1 years for major adverse cardiovascular events (MACEs; death or hospitalization for cardiac reasons). RESULTS: Seventeen patients (mean age 28.9 ± 11.4 years) were characterized as having depressive symptoms. According to univariate Cox regression analysis, the presence of depressive symptoms was independently associated with adverse clinical outcome. During the follow-up period, patients with depressive symptoms had a shorter event-free survival (1559 ± 92 days vs. 1077 ± 188 days, P = .00215) and a twofold higher risk of getting a MACE, compared with patients without (95% CI 1.630 to 3.616, P < .05). Based on receiver operator characteristics, the BDI had a better prognostic value for future MACEs (area under curve = 0.662, 95% CI 0.5442 to 0.7792; P < .05) compared with the Zung SDS. Mean event-free survival for patients with BDI ≥ 10 was 986 ± 179 days vs. 1624 ± 83 days for patients with BDI < 10. CONCLUSIONS: The incidence of depressive symptomatology in patients with CHD is rather high and is associated with poorer prognosis. The BDI seems to independently predict adverse clinical outcome. Standardized screening tools and psychosocial interventions to improve the well being of these patients should be a priority in the overall care of this population.

The Amplatzer Membranous VSD Occluder and the vulnerability of the atrioventricular conduction system.

Transcatheter closure of ventricular septal defects with the Amplatzer Membranous VSD Occluder has yielded promising initial results, but disturbances of conduction, including complete heart block, have been reported. We report our experience with the Amplatzer occluder in 35 patients with a median age 4.5 years, the defects being sized angiographically at 4.4 plus or minus 1.1 millimetres, with a range from 3 to 8 millimetres, and the size of the occluder varying from 4 to 12 millimetres. Over a median follow-up of 2.5 years, the rate of complete closure was 87% and 91%, at 1 and 2 years respectively, while 2 patients required surgical closure of the defect subsequent to the insertion of the device. Persistent regurgitation across the tricuspid valve related to the occluder was observed in 3 patients, and in 6 patients across the aortic valve. Abnormalities of conduction related to the procedure were noted in 7 patients, one-fifth of the cohort. The disturbances were transient in 1 patient, but permanent in 6, in one of the latter progressing after 6 months from left bundle branch block to intermittent Mobitz II second-degree atrioventricular block in association with expansion of the occluder. We conclude that transcatheter closure of perimembranous ventricular septal defects with the Amplatzer occluder is effective with limited complications, but the incidence of immediate and progressive disturbances of conduction related to the proximity of conduction tissues to the rims of the occluder stress the importance of larger and longer studies to assess the safety of this procedure.

Transcatheter closure of coronary arterial fistulas using the new Amplatzer vascular plug.

We report our initial experience in using the Amplatzer vascular plug for closure of coronary arterial fistulas. The self-expanding, cylindrical, device is made from Nitinol wire mesh, and is available from 4 to 16 millimetres in diameter. We have now used the device to close fistulas in 3 patients, aged from 3 to 14 years, who presented with ratios of pulmonary-to-systemic flow from 1.5 to 3. In 2 patients, fistulas arising from the proximal right and left coronary arteries, with maximal diameters of 9 and 10 millimetres, respectively, had their narrowest diameter, of 6 millimetres, proximal to the entrance into the right atrium via a saccular aneurysm. The third fistula, with a maximal diameter of 16 millimetres, and with its origin from the circumflex coronary artery, entered the right atrium with nearly unrestricted flow, its narrowest diameter being 8 millimetres. For interventional closure, we chose plugs twice the diameter of the narrowest segment of the fistula, thus using 2 devices of 12 millimetres and one of 16 millimetres diameter. An arteriovenous loop was established through the fistula by snaring an exchange guide wire. Using a 7 or 8 French guide catheter inserted through the femoral vein, all plugs were placed at the narrowest segment of the fistula, leading to immediate complete closure of 2 fistulas. The third patient, with a fistula of the circumflex coronary artery, who received the largest plug initially had residual flow, but the fistula was found to be completely occluded at 12 months follow-up examination. We have demonstrated, therefore, safe and effective usage of the new vascular plug for transcatheter closure of moderate- to large-sized coronary arterial fistulas. The plug offers an alternative to cardiac surgery, or occlusion using coils.

New xenograft valved conduit (Contegra) for right ventricular outflow tract reconstruction.

BACKGROUND: The well-known flaws of existing valved conduits for reconstruction of the right ventricular outflow tract (RVOT) continue to stimulate research for the elusive "perfect" conduit. In this study, we describe our experience with a glutaraldehyde-treated bovine jugular vein valved conduit (Contegra). METHODS: 55 years underwent implantation of a Contegra conduit. Diagnoses/procedures included repair of truncus arteriosus (2 patients), pulmonary atresia (3 patients), severe pulmonary insufficiency after prior repair of tetralogy of Fallot (9 patients), and replacement of degenerated valved conduit (1 patient). RESULTS: No operative deaths occurred. One patient required an early conduit replacement for unexplained valve thrombosis. The early postoperative mean transconduit pressure gradient was 7.7+/- 4.9 mm Hg. At a mean follow-up time of 18.5 +/- 6.9 months, all patients were asymptomatic with no discernible calcification in the valve or conduit or significant valve incompetence, while the mean transvalvular gradient remained low (11.1 +/- 4.5 mm Hg). CONCLUSION: The Contegra valved conduit is well suited for RVOT reconstruction, avoids the use of additional foreign material, and remains well functioning during early followup. Nonetheless, the long-term durability remains to be ascertained.