Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure.

Symmetrical peripheral gangrene (SPG) is a rare entity characterized by ischemic changes of the distal extremities with maintained vascular integrity. We present the case of a 64-year-old man with bilateral necrotic toes and deranged liver function tests. This was thought to be related to severely depressed ejection fraction from non-ischemic etiology, presumably chronic alcohol ingestion. We hope that awareness of SPG and association with a low output state will aid in early detection and prevention.

Adult presentation of subaortic stenosis: another great hypertrophic cardiomyopathy mimic.

Subaortic stenosis (SAS) is a rare entity in adults with an unclear aetiology and variable clinical presentations and outcomes. SAS typically tends to occur in the first decade of life either as an isolated lesion or in association with other congenital heart diseases. The clinical presentation of SAS can closely mimic hypertrophic cardiomyopathy (HCM) with obstructive physiology. We present two cases of SAS in adults that were initially presumed to be HCM. The patients were in their late forties and were referred to HCM clinic for further evaluation. Careful review of the transthoracic echocardiogram was indicative for the presence of possible subaortic membrane. These patients underwent subsequent imaging studies that completed the diagnosis for SAS and thereafter had successful surgical resection of the subaortic membrane. Subaortic stenosis remains a rare and clinically challenging diagnosis in the adult population. Often a combination of imaging modalities is needed to distinguish SAS from HCM with obstruction. It is critical to make the appropriate diagnosis as the treatment options are vastly different from the SAS and HCM with obstruction as well as the implications of a diagnosis of HCM with regards to risk of sudden death and family screening.

Training for Marathons during a Marathon Pandemic: Effect of the COVID-19 Pandemic on Fitness among High-Level Nonelite Runners.

BACKGROUND: The COVID-19 pandemic has had a profound effect on all aspects of life, including physical fitness and well-being of the general population. In the present study, we assessed the effect of the pandemic on the subjective and objective fitness of high-level nonelite runners. METHODS: The MASTERS Athletic Study is an ongoing survey of training and health habits of high-level nonelite runners, the majority of whom compete in marathons and other extreme endurance events. We invited participants to a web-based questionnaire regarding training and fitness during the COVID-19 pandemic. Comparisons were made between subjective and objective fitness as well as well as the relationship of prepandemic training volume and history of COVID-19 on change in fitness during the pandemic, using Mann-Whitney rank-sum tests and chi-square tests for nonparametric and categorical variables, respectively. RESULTS: A total of 189 runners completed the survey, of whom 26 (13.8%) reported prior diagnosis with COVID-19. In terms of the subjective sense of fitness compared to before the pandemic, 49 (25.9%) reported they were less fit, 55 (29.1%) reported they were more fit, and 85 (45.0%) reported their fitness was unchanged. These assessments correlated well with objective measurement of training volume in MET-min/week. Runners with improved fitness at present had a lower calculated training volume before the pandemic versus those who reported unchanged or worsened fitness. There was no relationship between the report of prior COVID-19 and either subjective or objective measures of fitness. CONCLUSION: The COVID-19 pandemic has had a variable effect on the fitness of high-level nonelite runners. We found an inverse relationship between baseline training volume and the likelihood of runners reporting improved fitness and no relationship between a history of COVID-19 and change in fitness through the pandemic. Understanding the effect of the COVID-19 pandemic on athletic fitness will help guide strategies to maintain physical health and wellness through future public health crises.

Serotonin syndrome following left ventricular assist device implantation: A report and institution-specific strategy for prevention.

Serotonin syndrome is a potentially lethal complication of antidepressant therapy. Cardiac surgical patients are at particularly high risk of serotonin syndrome due to the prevalence of depression in patients with advanced cardiac disease, many of whom receive multiple serotonergic agents in the perioperative period. Here, we describe a case of postoperative serotonin syndrome following methylene blue administration for perioperative vasoplegia during left ventricular assist device implantation. We additionally describe an institution-specific strategy to minimize future occurrences of serotonin syndrome in this high-risk population. .

Use of Cangrelor as a Bridge to Left Ventricular Assist Device Implantation in a Patient with a Recent Drug-Eluting Stent Who Developed Acute Tirofiban-Related Thrombocytopenia.

Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor following drug-eluting coronary artery stent implantation. In patients with recently implanted coronary artery stents who require urgent cardiac or noncardiac surgery, the benefits of maintaining oral dual antiplatelet therapy must be carefully weighed against the risks of excessive bleeding, and current practice is largely guided by individual surgeon preferences. When the effects of a second oral antiplatelet agent are undesirable during the perioperative period, the use of a short-acting intravenous antiplatelet agent as "bridge" therapy that can be discontinued shortly before surgery is associated with a reduced occurrence of adverse clinical events in patients with recently implanted coronary stents requiring urgent coronary artery bypass graft surgery. Cangrelor is an intravenous adenosine triphosphate analog P2Y12 receptor antagonist with a short plasma half-life that has been used off label in patients with recent coronary stents as a bridge to invasive procedures with excessive bleeding risk. To our knowledge, this is the first case report to demonstrate the safe and effective use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recently implanted drug-eluting coronary artery stent who developed acute thrombocytopenia following reexposure to tirofiban, a glycoprotein IIb/IIIa inhibitor.