Right ventricular dysfunction in stress cardiomyopathy: The prognostic value of fractional area change.

BACKGROUND: There are limited data on the impact of right ventricular dysfunction (RVD) on the clinical outcomes in patients with stress cardiomyopathy (SC). The purpose of this study was to evaluate the impact of RVD on outcomes and to characterize the prognostic value of RV fractional area change (FAC). METHODS: This study retrospectively analyzed data from 111 consecutive patients with SC. The primary endpoint, major cardiac events (MCE), was a composite of 30-day mortality, cardiogenic shock, life threatening arrhythmias, and stroke. Regression analysis was used to identify independent predictors of short (30 days)- and long-term MCE. RESULTS: Among the 111 patients (80.2% females, mean age 45.8 ± 11.5 years), RVD was present in 17(15.3%) patients. MCE occurred in 18(16.2%) and 22(19.8%) patients at 30 days and during long-term follow-up, respectively. RVD was an independent predictor of short (HR 1.88(1.21-15.67), P = .036)- and long (HR 1.65(1.11-9.67), P = .016)-term MCE. Compared with tricuspid annular plane systolic excursion < 15 mm (TAPSE) (sens 72.2%, spec 94.1%, AUC 0.75) and tricuspid annulus pulsed TDI-derived peak systolic velocity (S') < 9.5 cm/s (sens 67.2%, spec 94.5%, AUC 0.72), RV FAC < 30% (sens 89.1%, spec 100%, AUC 0.92) had the highest accuracy and discriminative ability to predict MCE. Furthermore, RV FAC < 30% was a significant predictor of recurrence (29.4% vs 2.1%, P = .002) and delayed recovery time (21.4 ± 6.8 vs 8.5 ± 4.3 days, P < .001). CONCLUSIONS: The presence of RVD in stress cardiomyopathy identifies patients at higher risk of mortality, complications, delayed recovery, and recurrence. Compared with other indices, RV FAC has the highest prognostic ability to predict these outcomes.

The prognostic value of dispersion of repolarization in stress cardiomyopathy.

INTRODUCTION: Although abnormalities of ventricular repolarization are a hallmark of SC, their clinical impact on management remains to be determined. This study sought to evaluate the prognostic value of dispersion of repolarization in stress cardiomyopathy (SC) with regards to major cardiac events (MCE), recovery time, and recurrence. METHODS: This study analyzed data from258 patients with SC, from January 2009 to January 2018. Standard 12 lead ECG recordings during the acute, subacute, and recovery phases were collected for each eligible patient. Logistic regression was used to identify independent predictors of MCE, a composite of 30 day all-cause mortality, cardiogenic shock, life-threatening ventricular arrhythmias, and stroke. RESULTS: Among the 101 eligible patients (80.2% females, mean age 45.8 ± 11.5 years) in the study cohort, MCE occurred in 16 patients (15.8%). Cox regression analysis identified two independent predictors of MCE: increased ΔQT dispersion ≥ 40 ms (HR 1.31, 95% CI 1.05-9.77, p = 0.029) and increased Δnegative T wave amplitude dispersion ≤ -2.0 mV (HR 1.25, 95% CI 1.11-11.93, p = 0.018) during the subacute phase. The final regression model had good accuracy (sensitivity 81.3%, specificity 96.5%) and discriminative power (AUC 0.89, 95% CI 0.83-0.95). Kaplan-Meier analysis revealed that there was increasing MCE in patients with zero, one, or two predictors (log rank p < 0.001). In addition, patients with increased dispersion also had a significantly longer time to achieve complete recovery (21.4 ± 6.8 vs. 8.5 ± 4.3 days, p = 0.012) and a higher incidence of recurrence (31.3% vs. 2.4%, p = 0.011) of SC. CONCLUSION: Evaluation of dynamic changes of dispersion of repolarization is a simple bed-side tool with high predictive accuracy for prognostication of short term adverse outcomes, delayed recovery, and recurrence in patients with SC.

Cardiac anaphylaxis: a case of acute ST-segment elevation myocardial infarction after IM epinephrine for anaphylactic shock.

A 62-year-old male smoker with no other comorbidities presented to emergency department with systemic anaphylaxis, due to oral diclofenac for toothache. He developed acute anterior wall myocardial infarction following IM epinephrine 1 mg 1:1000. Primary percutaneous coronary intervention was done, which showed a thrombus in the mid left anterior descending artery with no evidence of obstructive coronary artery disease after thrombus aspiration.

Personalized allocation of acetylsalicylic acid therapy for secondary prevention of coronary artery disease.

Background: A single-daily dose of 75 mg of acetylsalicylic acid inhibits 100% of thromboxane-B2 synthesis within 30-60 min. Thromboxane-B2 synthesis then recovers slowly as new platelets are released from the bone marrow. Normally, only 10% of the platelets are replaced daily by new platelets entering circulation. Hence, 24 h after a dose of acetylsalicylic acid, thromboxane-B2 synthesis is still suppressed by more than 90%. Hence, there is an adequate anti-platelet effect even after 24 h of acetylsalicylic acid intake. However, some patients treated with once-daily acetylsalicylic acid may have an incomplete 24-h suppression of thromboxane-B2 synthesis due to increased platelet turnover. The response could be improved in such patients by twice-daily acetylsalicylic acid administration. This study aimed to identify such a group of patients who would benefit from a twice-daily dose of acetylsalicylic acid. Materials and methods: Serum thromboxane-B2 levels were measured in 79 patients with coronary artery disease receiving 75 mg of acetylsalicylic acid for secondary prophylaxis. Serum levels of thromboxane-B2 were measured after 4 and 24 h of acetylsalicylic acid intake. Patients were then classified into three groups: steady suppression group (serum thromboxane B2 is adequately suppressed at 4 and 24 h), i.e., adequate response to acetylsalicylic acid; fast recovery group (more than 10% rise in serum thromboxane-B2 levels at 24-h when compared to at 4-h) and non-responders (serum thromboxane-B2 levels of >3,100 pg/ml after 4 h of acetylsalicylic acid intake). Patients in the fast recovery group were given twice-daily acetylsalicylic acid and thromboxane-B2 levels were re-measured. Results: A total of 20 patients (24.3%) had steady suppression of thromboxane-B2 and 11 patients (13.9%) belonged to the fast recovery group, i.e., thromboxane-B2 levels were adequately suppressed at 4 h but had recovered by more than 10% at 24 h; which was adequately suppressed by twice-daily acetylsalicylic acid (p 0.004). A total of 48 patients (60.8%) were non-responders. Conclusion: Twice-daily acetylsalicylic acid may be beneficial if serum thromboxane-B2 levels at 4 h are <3,100 and >3,100 pg/ml at 24 h. If thromboxane-B2 levels at 4 and 24 h is <3100 pg/ml but if there is a >10% rise in serum thromboxane B2 at 24 h as compared to that at 4 h, then twice-daily acetylsalicylic acid should be considered. However, if thromboxane-B2 at 4 and 24 h is >3,100 pg/ml consider switching over to a P2Y12 inhibitor.

Evaluating the Efficacy, Toxicity and Pharmacokinetic Profile of Oral Busulfan in Allogeneic Stem Cell Transplant Patients.

Background: Oral busulfan and intravenous cyclophosphamide (Bu/Cy) are common myeloablative preparations used in allogeneic hematopoietic stem cell transplantation (HSCT). Herein, we investigated the safety of (Bu/Cy) administration during HSCT. Methods: Patients administered Bu/Cy for allogeneic HSCT at Royal Perth Hospital and Fiona Stanley Hospital between 2007 and 2017 were reviewed for inclusion in the study. We performed busulfan pharmacokinetic (PK) testing for a subset of patients and allometric scaling modeling to assess the best method of busulfan dosing in patients at extremes of weight. Results: Sixty-nine patients were included in the clinical outcome analysis. The median follow-up period was 32 months (range, 9-114 months). The three-year overall survival rate was 62% (95% confidence interval (CI), 51%-75%), and transplant-related mortality was 4% at 6 months (95% CI, 1-7%), with a low rate of sinusoidal obstruction syndrome of the liver being observed. In addition, relapse was 38% (95% CI, 30%-44%) at 3 years. The PK information of 15 patients receiving busulfan was available after oral dosing. The average per-dose busulfan exposure was 1,350 µmol.min/L (range, 878-1,717 µmol.min/L), and the within target range was 1,000-1,500 µmol.min/L in 73% of patients. Of the size measures investigated, ideal and adjusted body weight (ABW40) provided the best fit. No association was observed between busulfan exposure, toxicity, and relapse. Conclusions: Overall, Bu/Cy administration appeared safe when dosed in relation to weight, showing a low early transplant-related mortality rate following adequate busulfan exposure in majority of the cases. Body size measures, such as ideal body weight or ABW40, are likely more suitable for use during busulfan dosing, particularly at high extremes of the body mass index classification.

Timing of adverse events during fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis.

Serious bleeding and embolic events are common after fibrinolytic therapy (FT) for left-sided prosthetic valve thrombosis (PVT), and are believed to occur more frequently with prolonged fibrinolytic infusions. But there is no data from prospective studies examining this contention. Our aim was to determine the timing of adverse events after FT with streptokinase (SK) for left-sided PVT. In a post-hoc analysis involving all 120 participants from a randomized controlled trial of FT for left-sided PVT, we determined the timing of occurrence of a composite of death, major bleeding, embolic stroke, or non-central nervous system systemic embolism, in relation to the duration of SK infusion. The composite outcome occurred in 20 (16.7%) of the 120 patients. Adverse events were more frequent within 12 h of initiating treatment than later (28% vs. 10%; OR 3.75, 95% CI 1.25-11.20, P = 0.018). Contrary to current thinking, adverse events can occur early during fibrinolytic therapy for left-sided PVT. This has important implications for the use of fibrinolysis as first line treatment for left-sided PVT.

An adult patient with previously undiagnosed sinus venosus atrial septal defect presenting with brain abscess: a case report.

BACKGROUND: Brain abscess is a common complication in children with cyanotic congenital heart disease. The presence of an underlying acyanotic congenital heart disease is usually not suspected in an adult patient presenting with brain abscess. CASE SUMMARY: A 51-year-old male patient with no known co-morbidities came with complaints of recent onset right lower limb weakness needing support while walking and on evaluation was found to have brain abscess. He underwent robotic endoscope assisted endoport excision of the brain abscess. Two-dimensional transthoracic echocardiography showed right atrial and right ventricular dilatation with mild low-pressure tricuspid regurgitation. Transoesophageal echocardiography (TOE) revealed sinus venosus atrial septal defect (ASD) with left-to-right shunt with the right upper pulmonary vein draining into superior vena cava. Contrast echocardiography revealed a small transient right-to-left shunt. He has been advised to undergo elective surgical closure of ASD with partial anomalous pulmonary venous connection repair. DISCUSSION: Right-to-left shunting in ASDs can occur in the early systole even in the absence of raised pressures in the right side of the heart, even when the predominant shunt is left to right, but the magnitude of such a shunt is small and transient and is easily missed. Contrast echocardiography and TOE should be done as a part of evaluation of patients presenting with brain abscess.

Accelerated infusion of streptokinase for the treatment of left-sided prosthetic valve thrombosis: a randomized controlled trial.

BACKGROUND: No large prospective studies have evaluated the efficacy of fibrinolytic therapy for left-sided prosthetic valve thrombosis, yet it remains the first line of treatment in developing countries. METHODS AND RESULTS: We performed a randomized controlled trial comparing an accelerated infusion with the conventional infusion of streptokinase in 120 patients with a first episode of left-sided prosthetic valve thrombosis. The primary outcome measure was the occurrence of a complete clinical response, defined as objectively documented complete restoration of valve function in the absence of major complications. The secondary outcome was a composite of death, major bleeding, embolic stroke, or non-central nervous system systemic embolism. Patients were recruited over a 2.5-year period at a single center in India. Complete clinical response occurred in 38 (64.4%) of 59 patients with the accelerated infusion compared with 32 (53.3%) of 60 with the conventional infusion (hazard ratio 1.6, 95% confidence interval 0.9 to 2.5, P=0.055). There was no significant difference in the occurrence of the composite secondary outcome (hazard ratio 1.4, 95% confidence interval 0.5 to 3.5, P=0.50) or major bleeding (hazard ratio 2.2, 95% confidence interval 0.6 to 7.7, P=0.24) with the accelerated infusion. The success rate with fibrinolytic therapy was low overall (59%) and very low in patients in New York Heart Association functional class III/IV (24%). CONCLUSIONS: The large number of patients recruited from a single center underscores the massive burden of prosthetic valve thrombosis in developing countries. Fibrinolytic therapy with streptokinase is less efficacious than previously believed. The accelerated streptokinase infusion is not better than the standard infusion for left-sided prosthetic valve thrombosis. Developing countries urgently need more effective strategies to prevent and treat prosthetic valve thrombosis.

Changes in Left Ventricular Mass and Cardiovascular Risk Factors after Kidney Transplantation.

Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m2, P <0.001) and improvement in ejection fraction (57.8 ± 7 vs. 60.1 ± 1.9, P = 0.015) at the end of six months. There were significant differences in the mean hemoglobin, systolic, and diastolic blood pressures (P <0.001) during the study. There was also a significant reduction in the number of antihypertensive drugs required for blood pressure control. There was a significant reduction in LVH in the study group. There was also improvement in systolic and diastolic functions of the heart. There was also a significant improvement in blood pressure control both in terms of mean blood pressure levels as well as in terms of the number of anti-hypertensive drugs needed for blood pressure control. Renal transplantation ameliorates cardiovascular risk in renal transplant recipients.

Phenotypic expression and clinical outcomes in a South Asian PRKAG2 cardiomyopathy cohort.

The PRKAG2 syndrome is a rare autosomal dominant phenocopy of sarcomeric hypertrophic cardiomyopathy (HCM), characterized by ventricular pre-excitation, progressive conduction system disease and left ventricular hypertrophy. This study describes the phenotype, genotype and clinical outcomes of a South-Asian PRKAG2 cardiomyopathy cohort over a 7-year period. Clinical, electrocardiographic, echocardiographic, and cardiac MRI data from 22 individuals with PRKAG2 variants (68% men; mean age 39.5 ± 18.1 years), identified at our HCM centre were studied prospectively. At initial evaluation, all of the patients were in NYHA functional class I or II. The maximum left ventricular wall thickness was 22.9 ± 8.7 mm and left ventricular ejection fraction was 53.4 ± 6.6%. Left ventricular hypertrophy was present in 19 individuals (86%) at baseline. 17 patients had an WPW pattern (77%). After a mean follow-up period of 7 years, 2 patients had undergone accessory pathway ablation, 8 patients (36%) underwent permanent pacemaker implantation (atrio-ventricular blocks-5; sinus node disease-2), 3 patients developed atrial fibrillation, 11 patients (50%) developed progressive worsening in NYHA functional class, and 6 patients (27%) experienced sudden cardiac death or equivalent. PRKAG2 cardiomyopathy must be considered in patients with HCM and progressive conduction system disease.

Comparison of clinical and electrophysiological characteristics between ictal and cardiac asystole encountered during video-EEG monitoring.

Differentiation between syncope secondary to epileptic seizures and cardiac disease in patients displaying transient loss of consciousness associated with convulsive movements is a diagnostic challenge both for neurologists and cardiologists. In such patients, prolonged video-EEG monitoring not only helps in identifying asystole as the cause of syncope, but also in categorizing asystole as primarily cardiac in origin (cardiac asystole) and secondary to epileptic seizures (ictal asystole). We carried out this study to ascertain the prevalence of asystole in an epilepsy monitoring unit, and to contrast the clinical and electrophysiological characteristics between ictal asystole and cardiac asystole. Through a retrospective search, we identified patients who were shown to have had asystole using a database of patients who underwent prolonged video-EEG monitoring during a 68-month period. We compared the data of 18 consecutive patients; five with ictal asystole and 13 with cardiac asystole, with 121 and 64 events recorded from them, respectively. Of the 10,096 patients who underwent prolonged video-EEG monitoring during the study period, we identified 18 (0.17%) patients with asystole. Cardiac asystole was 2.6 times more frequent than ictal asystole. Older age at onset, heralding symptoms of presyncope, occurrence during wakefulness, and brief duration of the events supported the diagnosis of cardiac asystole. Ictal asystole events were more protracted, and prolonged asystole more frequently occurred in patients with extratemporal seizures compared to temporal lobe seizures. Asystole occurred in only half of the recorded seizures. The accurate categorization of asystole as seizure-related or heart disease-related has huge implications for management strategy and outcome. The necessity of permanent pacemaker implantation is more frequent and urgent in patients with cardiac asystole because of the greater risk of sudden death. Hence, in patients with an ominous diagnosis of cardiac asystole, a thorough cardiac evaluation should surpass neurological evaluation.

Young Stroke: An Unusual Presentation of Arrhythmogenic Right Ventricular Dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) is an underdiagnosed cardiomyopathy which commonly presents in young adults with ventricular tachycardia or sudden cardiac death. We report a case of ARVD presenting with features of acute ischemic cerebrovascular stroke. The suspicion of ARVD came only when the echocardiogram revealed dilatation and abnormal wall motion of the right ventricle in the presence of certain ECG findings consistent with ARVD. The diagnosis was later confirmed by cardiac MRI which is one of the most specific diagnostic tests for ARVD.

Primary transcatheter closure of post-myocardial infarction ventricular septal rupture using amplatzer atrial septal occlusion device: A study from tertiary care in South India.

OBJECTIVE: The study investigated effectiveness of transcatheter closure of post-myocardial infarction (MI) ventricular septal rupture (VSR) using atrial septal device (ASD) occluder in a cohort of patients admitted at our institute. METHOD: This was a retrospective, observational and single center study, which included patients who were treated with transcatheter closure for post-MI VSR at our tertiary care center between May 2000 and August 2014 depending upon inclusion and exclusion criteria. Primary outcome was all-cause mortality at 30-days follow-up. The MELD-XI (Model for End Stage Liver Disease) score was used as a predictor for poor outcome in these patients. RESULTS: A total of 21 patients (mean age 66.4±5.9years) were included in the study. Study cohort predominantly included male patients (n=15; 71.4%) and patients with single vessel disease (n=15; 71.4%). Revascularization of the culprit lesion, before VSR closure, was attempted in 6 patients. Except one patient (treated with Cera® occluder), all patients were treated with Amplatzer® ASD occluders. Average diameter of VSR was 20.8±6.9mm. Diameter of the device used in the study ranged from 10mm to 30mm. Residual defect was detected in 13 patients (62%). All-cause mortality at 30-day follow-up was observed in 9 (42.9%) patients. Time to VSR closure, diameter of VSR, and serum creatinine levels were significantly related to the 30-day mortality. MELD-XI score was found to be strongly associated with increased risk of mortality. CONCLUSION: Primary transcatheter VSR closure using ASD occluders is a feasible approach which can provide reasonable survival outcomes along with equitable mortality rates.

Surviving All Odds: A Unique Case of Multiple Congenital Unruptured Sinus of Valsalva Aneurysms Involving Both Left and Right Coronary Sinuses with Biventricular Dysfunction and Heart Block.

Aneurysms of the sinus of Valsalva are very uncommon, with an incidence ranging from 0.1 to 3.5% of all congenital heart defects. Very few cases have been reported in the literature that presented with involvement of two or more sinuses. We report a case of 27-year-old male with a history of exertional breathlessness of one-month duration. After complete evaluation using transesophageal echocardiography (TEE) and multiple detector computed tomography (MDCT) scanning, the patient was diagnosed to have large congenital unruptured sinus of Valsalva aneurysms involving both left and right coronary sinuses with extension into the interventricular septum. The patient also displayed second-degree heart block (Mobitz type 2) and biventricular dysfunction. The patient was managed successfully. We present the case with an aim to highlight the management challenges including intraoperative and postoperative complications that are associated with unruptured sinus of Valsalva aneurysms of ≥2 sinuses.

A Rare Case of Fatal Endocarditis and Sepsis Caused by Pseudomonas aeruginosa in a Patient with Chronic Renal Failure.

Nosocomial catheter-related and Arteriovenous fistula (AV)-related infections are significant concern in patients undergoing haemodialysis. These infections are associated with multiple complications as well as mortality and demands immediate and appropriate management. While coagulase-negative staphylococci, S.aureus, and Escherichia coli are the most common causes of catheter-related infections in haemodialysis patients, such infections caused by Pseudomonas aeruginosa are relatively rare. Here, we present an unusual case of 36-year-old male patient with chronic renal failure, who developed endocarditis and sepsis from Pseudomonas aeruginosa infection of the left hand arteriovenous fistula. The bacteraemia in the present case caused multiple complications including dry gangrene of bilateral lower limbs, stroke, endophthalmitis, left brachial artery thrombosis and vegetations on the interventricular septum and aortic wall. Despite antibiotic treatment, the patient suffered a cardiac arrest and could not be revived.

A randomized study of coconut oil versus sunflower oil on cardiovascular risk factors in patients with stable coronary heart disease.

BACKGROUND AND RATIONALE: Coronary artery disease (CAD) and its pathological atherosclerotic process are closely related to lipids. Lipids levels are in turn influenced by dietary oils and fats. Saturated fatty acids increase the risk for atherosclerosis by increasing the cholesterol level. This study was conducted to investigate the impact of cooking oil media (coconut oil and sunflower oil) on lipid profile, antioxidant mechanism, and endothelial function in patients with established CAD. DESIGN AND METHODS: In a single center randomized study in India, patients with stable CAD on standard medical care were assigned to receive coconut oil (Group I) or sunflower oil (Group II) as cooking media for 2 years. Anthropometric measurements, serum, lipids, Lipoprotein a, apo B/A-1 ratio, antioxidants, flow-mediated vasodilation, and cardiovascular events were assessed at 3 months, 6 months, 1 year, and 2 years. RESULTS: Hundred patients in each arm completed 2 years with 98% follow-up. There was no statistically significant difference in the anthropometric, biochemical, vascular function, and in cardiovascular events after 2 years. CONCLUSION: Coconut oil even though rich in saturated fatty acids in comparison to sunflower oil when used as cooking oil media over a period of 2 years did not change the lipid-related cardiovascular risk factors and events in those receiving standard medical care.