Post-myocardial Infarction Ventricular Septal Defect in the Setting of No-Reflow and COVID.

The occurrence of post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but life-threatening complication. This case report presents a unique case of a 49-year-old female patient with an anterolateral ST-segment elevation MI who underwent percutaneous coronary intervention (PCI) and drug-eluting stent (DES) placement, complicated by a no-reflow phenomenon in the distal left anterior descending artery (LAD) and subsequent development of a hemodynamically significant VSD. Notably, this case occurred during the COVID-19 pandemic, which added to the complexity of the patient's management. The patient's clinical course was further complicated by cardiogenic shock, acute respiratory failure, COVID-19 pneumonia, and gastrointestinal bleeding. Despite these challenges, the patient received prompt treatment and optimal medical management, including the use of vasopressor support, insulin therapy, and bicarbonate infusions. The patient also underwent surgical repair of the VSD at a quaternary center, resulting in a favorable outcome. This case report highlights the increased incidence of mechanical complications, such as VSD, during the COVID-19 pandemic due to delayed presentation and patient concerns about exposure to the virus. It also emphasizes the occurrence of a no-reflow phenomenon during PCI, which can lead to adverse outcomes, including larger infarct size and potential ventricular septal rupture. The case further underscores the importance of multidisciplinary collaboration and early subspecialist involvement in managing complex cases of post-MI VSD.

Unusual Fungal Endocarditis Causing Disseminated Infection After Renal Transplant.

Fungal endocarditis is a relatively uncommon disease; it mostly affects those with intracardiac devices and those with compromised immune systems. Scedosporium apiospermum (S. apiospermum), the asexual state of Pseudoallescheria boydii, has become increasingly reported as an opportunistic pathogen. These filamentous fungi present in soil, sewage, and polluted waters, and was previously recognized to cause human infection after their inhalation or traumatic subcutaneous implantation. In immunocompetent individuals, it usually causes localized diseases depending on the site of entry such as skin mycetoma. However, in immunocompromised hosts, the fungus species appear to disseminate and cause invasive infections, frequently reported to be life-threatening with poor response to antifungal medications. S. apiospermum invasive endocarditis remains a rare complication, mostly cited in immunocompetent hosts with prosthetic cardiac valves or other intracardiac devices and severely immunocompromised patients with hematologic neoplasia. Herein, we describe the case of a renal transplant patient on immunosuppressive medications who presented with S. apiospermum fungal septic infection that invaded the left ventricular outflow tract (LVOT) causing endocarditis with disseminated infection and resulted in poor clinical outcome.

Risk of post-intubation cardiac arrest with the use of high-dose rocuronium in COVID-19 patients with acute respiratory distress syndrome: A retrospective cohort study.

BACKGROUND: Post-intubation cardiac arrest (PICA) is an uncommon complication of intubation, but numbers have risen to over 1.5 times the usual number since the coronavirus disease 2019 (COVID-19) pandemic. Due to expert recommendations, high-dose rocuronium (HDR) has become a commonly used pre-intubation neuromuscular blocking agent. AIM: We conducted this retrospective case-control observational study with the hypothesis that high-dose rocuronium was not associated with higher incidence of PICA. METHODS: We included 93 patients who were intubated using the rapid sequence intubation (RSI) technique with rocuronium for acute respiratory distress syndrome (ARDS) due to confirmed COVID-19 pneumonia, admitted from March 2020 to February 2021 to a tertiary care hospital in North Carolina, USA. The patients were grouped based on high (1.5 mg/kg of ideal body weight and above) versus low (<1.5 mg/kg of ideal body weight) dose rocuronium used for RSI. The differences of the various outcomes between the groups were analyzed. RESULTS: The baseline demographics were similar in both groups except for higher body mass index in high-dose group 39 versus 32 (kg/m2), p = 0.009. There was a total of six PICA events (6.45%). The HDR group had 8.0% of PICA versus 4.7% in the low-dose group. In-hospital mortality was 60.0% in the HDR group versus 72.1% in the low-dose group. CONCLUSION: The incidence of PICA in COVID-19 patients with ARDS who were intubated using the RSI technique was higher than in the pre-COVID-19 era. RELEVANCE FOR PATIENTS: The use of high-dose paralytics during invasive ventilation with RSI and their consequences should be explored with the help of large-scale studies. The rate of PICA is still very low, and perhaps, the use of HDR is safe, as suggested by the expert panel.

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study.

BACKGROUND: The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data. METHODS: The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation. RESULTS: The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82-0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93-1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90-0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus. CONCLUSION: The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.

ACTH Gel in Resistant Focal Segmental Glomerulosclerosis After Kidney Transplantation.

BACKGROUND: Treatment of focal segmental glomerular sclerosis (FSGS) after kidney transplantation is challenging with unpredictable outcomes. The objective was to investigate the use of adrenocorticotropic hormone (ACTH) analogue gel in kidney transplant recipients with de novo or recurrent FSGS resistant to therapeutic plasma exchange (TPE) and/or rituximab. METHODS: We performed a retrospective review of cases of de novo or recurrent resistant FSGS at 2 large US transplant centers between April 2012 and December 2016. Proteinuria was measured by urine protein to creatinine ratio. RESULTS: We identified 20 cases of posttransplant recurrent and de novo FSGS resistant to conventional therapy with TPE and rituximab. Mean ± SD age was 49 ± 15.5 years, 14 (70%) were male, 13 (65%) were whites, and 8 (38%) had previous kidney transplants. Median (interquartile range) of recurrent and de novo FSGS was 3 (0.75-7.5) months posttransplant. The majority of patients, 15 (75%), received TPE as a treatment at the time of diagnosis and 10 (50%) received rituximab, which was started before the use of ACTH gel. There was a significant improvement of urine protein to creatinine ratio from a mean ± SD of 8.6 ± 7.6 g/g before ACTH gel to 3.3 ± 2.3 g/g after the use of ACTH gel (P = 0.004). Ten (50%) patients achieved complete or partial remission. CONCLUSIONS: Although, the response varied among the recipients, ACTH gel might be an effective therapy for posttransplant resistant FSGS cases that fail to respond to TPE and rituximab.

Coronary Subclavian Steal Syndrome: An Unusual Cause of Angina in a Post-CABG Patient.

Coronary subclavian steal syndrome is a rare complication of coronary artery bypass grafting surgery (CABG) when a left internal mammary artery (LIMA) graft is utilized. This syndrome is characterized by retrograde flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. We describe a unique case of an elderly male who underwent CABG 6 years ago who presented with prolonged chest pain, mildly elevated troponins, and unequal pulses in his arms. A CTA of the chest demonstrated a severely calcified occluded proximal left SA jeopardizing his LIMA graft. Subclavian angiography was performed with an attempt to revascularize the patient's occluded left SA which was unsuccessful. We referred the patient for nuclear stress testing which demonstrated a moderate size area of anterior ischemia on imaging; the patient exercised to a fair exercise capacity of 7 METS with no chest pain and no ECG changes. Subsequent coronary angiography showed severe native three-vessel coronary artery disease with intermittent retrograde blood flow from the LIMA to the left SA distal to the occlusion, jeopardizing perfusion to the left anterior descending (LAD) coronary artery distribution. He declined further options for revascularization and was discharged with medical management.

Differences in mean and variability of heart rate and ambulatory rate-pressure product when valsartan or carvedilol is added to lisinopril.

Guidelines recommend combining ß-blockers and angiotensin-converting enzyme (ACE) inhibitors in high-risk heart disease but not in the initial treatment of hypertension. The mechanism of this benefit has not been determined. After 3 weeks of lisinopril (L, 40 mg/day) run-in, 30 subjects entered a single-blinded, forced-titration, crossover study in which carvedilol (C, 20 then 40 mg/day) or a control renin-angiotensin blocker, valsartan (V, 160 then 320 mg/day) were added to L. Ambulatory blood pressure (ABP) and heart rate monitoring was performed at the end of each period. Rate-pressure product (RPP, systolic BP × heart rate, an indicator of cardiac oxygen consumption) was measured over 24 hours, daytime (6 am to midnight), and nighttime (midnight to 6 am) periods. Variability (standard deviation and range) of RPP, BP, and heart rate was also investigated. After 4 weeks, mean 24-hour systolic BP was about 8 mm Hg lower when either V or C was added to L (P < .01 each). Heart rate was consistently lower with C (8 beats/min over 24 hours, P < .000) but was slightly increased with V (about 2 beats/min, P = NS). Consequently, C lowered RPP to a greater degree than V over 24 hours (about 8% vs. 2%, P < .000) and during daytime and nighttime periods (P < .000 each). In addition, RPP variability (SD but not range) was consistently lower on C than V. When added to L, C reduces the mean and variability (SD) of 24-hour heart rate and cardiac workload to a greater degree than valsartan. These effects may contribute to the outcome benefits observed with ß-blocker-ACE inhibitor combinations.