Disparities and Outcomes in the First and Second Year of the Pandemic on Events of Acute Myocardial Infarction in Coronavirus Disease 2019 Patients.

Background and Objectives: Coronavirus disease 2019 (COVID-19) caused several cardiovascular complications, including acute myocardial infarction (AMI), in infected patients. This study aims to understand the overall trends of AMI among COVID-19 patients during the first two years of the pandemic and the disparities and outcomes between the first and second years. Materials and Methods: The retrospective analysis was conducted via the 2020 and 2021 National Inpatient Sample (NIS) database for hospitalizations between April 2020 and December 2021 being analyzed for adults with a primary diagnosis of COVID-19 who experienced events of AMI. A comparison of month-to-month events of AMI and mortality of AMI patients with concomitant COVID-19 was made alongside their respective patient characteristics. Results: Out of 2,541,992 COVID-19 hospitalized patients, 3.55% experienced AMI. The highest rate of AMI was in December 2021 (4.35%). No statistical differences in trends of AMI mortality were noted over the 21 months. AMI cases in 2021 had higher odds of undergoing PCI (aOR 1.627, p < 0.01). They experienced higher risks of acute kidney injury (aOR 1.078, p < 0.01), acute ischemic stroke (aOR 1.215, p < 0.01), cardiac arrest (aOR 1.106, p < 0.01), need for mechanical ventilation (aOR 1.133, p < 0.01), and all-cause mortality (aOR 1.032, 95% CI 1.001-1.064, p = 0.043). Conclusions: The incidence of AMI among COVID-19 patients fluctuated over the 21 months of this study, with a peak in December 2021. COVID-19 patients reporting AMI in 2021 experienced higher overall odds of multiple complications, which could relate to the exhaustive burden of the pandemic in 2021 on healthcare, the changing impact of the virus variants, and the hesitancy of infected patients to seek care.

Use of Unique Doppler Flow-Pattern for the Diagnosis of Left Ventricular Diverticulum.

Isolated congenital left ventricular diverticulum (LV) is reportedly a rare finding. It is frequently associated with other congenital defects involving heart, pericardium, sternum, diaphragm, and abdominal wall. It is an outpouching from the ventricle and has all three layers of left ventricular free walls. We present the case of a 53-year-old woman who was discovered to have an outpouching of the LV apex on a nongated chest CT scan raising possibility of a pseudoaneurysm. A transesophageal echocardiogram (TEE) showed systolic diminution of this outpouching with unique Doppler flow-patterns suggesting a diagnosis of a muscular type of LV diverticulum instead of a postinfarct LV pseudoaneurysm. The patient was reassured and treated conservatively.

Risks of hypertension and thromboembolism in patients receiving bevacizumab with chemotherapy for colorectal cancer: A systematic review and meta-analysis.

BACKGROUND: Guidelines show that for metastatic colorectal cancer (mCRC), a combination of three-drug regimens, fluorouracil, leucovorin, and oxaliplatin and bevacizumab (BVZ), is one of the first-line standard therapies. BVZ is generally well tolerated; however, it is associated with infrequent, life-threatening side effects such as severe hypertension (HTN) (5%-18%), Grade ≥3 arterial thromboembolism (ATE) (2.6%), Grade ≥3 hemorrhagic events (1.2%-4.6%), and gastrointestinal perforation (0.3%-2.4%). This meta-analysis aims to evaluate the additive risk of BVZ-induced severe HTN and thromboembolism when BVZ is combined with a standard chemotherapy regime in patients with mCRC. METHODS: Our search was conducted from January 29, 2022, to February 22, 2022, through databases of PubMed, clinicaltrial.gov, EMBASE, Web of Science, and Cochrane Library. Data analysis from randomized controlled trials (RCTs) and clinical trials was conducted using Review Manager V.5.4, comparing BVZ-chemotherapy to chemotherapy only, focusing on cardiovascular AE such as HTN and arterial and venous thromboembolism. RESULTS: The analysis from 26 clinical trials and RCTs showed that the odds of HTN were about four times higher, and ATE subgroup analysis of 11 studies showed over two times higher odds of ATE in patients being treated with BVZ compared to the chemotherapy-only group. CONCLUSION: BVZ, when added to the standard chemotherapy regimen for mCRC, was associated with higher odds of developing HTN and thromboembolism, specifically ATE, than the chemotherapy-only group. Our findings are significant as they provide vital information in analyzing the risk-benefit ratio of adding BVZ to the standard chemotherapy regime in patients with mCRC, especially in patients with vascular comorbidities.

Venous Thromboembolism in Metastatic Uterine Leiomyosarcoma: A Case Report and Review of the Literature.

We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.

'From Gut to Heart': A rare case of Salmonella Typhimurium Bacteremia and native valve endocarditis.

Background: Salmonella species are very rarely associated with infective endocarditis, accounting for less than 0.01-2.9 % of total bacterial endocarditis cases. Since 1976, there have less than 90 reported cases of non-Typhoidal Salmonella bacteremia and endocarditis. Case presentation: We present the case of a 57-year-old homeless man with a past medical history significant only for polysubstance abuse. He presented to the emergency department with a 3-day history of severe, non-bloody diarrhea, nausea, chills, and oliguria. Due to the patient's history of substance use, screening laboratory tests were conducted and were positive for rapid plasma reagin, treponemal antibodies, and hepatitis C. For the profuse diarrhea and severe volume loss, C. difficile, stool white blood cells and stool ova and parasites were ordered but were ultimately negative. Both sets of blood cultures were found to be positive for Salmonella Typhimurium bacteremia. Further workup with transthoracic and transesophageal echocardiogram displayed small mobile masses attached to the aortic surface of the right and non-coronary cusps, confirming endocarditis on the aortic valve. Treatment included penicillin-G once a week for 3 weeks for latent syphilis and ceftriaxone and levofloxacin for bacteremia and endocarditis. Conclusions: Patients with Salmonella typically present early with gastrointestinal symptoms, but clinicians should consider cardiovascular imaging if blood cultures are found to be positive in order to potentially identify and promptly treat highly fatal Salmonella endocarditis.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis.

AIM: Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis. RESULTS: The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%). CONCLUSIONS: There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Pathophysiology, Diagnosis, and Management of Coronary No-Reflow Phenomenon.

Coronary no-reflow phenomenon is a lethal mechanism of ongoing myocardial injury following successful revascularization of an infarct-related coronary artery. Incidence of this phenomenon is high following percutaneous intervention and is associated with adverse in-hospital and long-term outcomes. Several mechanisms such as ischemia-reperfusion injury and distal microthromboembolism in genetically susceptible patients and those with preexisting endothelial dysfunction have been implicated. However, the exact mechanism in humans is still poorly understood. Several investigative and treatment strategies within and outside the cardiac catheterization laboratory have been proposed, but they have not uniformly shown success in reducing mortality or in preventing adverse left ventricular remodeling resulting from this condition. The aim of this article is to provide a brief and concise review of the current understanding of the pathophysiology, clinical predictors, and investigations and management of coronary no-reflow phenomenon.

Pathophysiology, Diagnosis, and Management of Coronary No-Reflow Phenomenon.

Coronary no-reflow phenomenon is a lethal mechanism of ongoing myocardial injury, following successful revascularization of an infarct-related coronary artery. Incidence of this phenomenon is high following percutaneous intervention, and is associated with adverse in-hospital and long-term outcomes. Several mechanisms such as ischemia-reperfusion injury and distal microthromboembolism in genetically susceptible patients and those with preexisting endothelial dysfunction have been implicated. However, the exact mechanism in humans is still poorly understood. Several investigative and treatment strategies within and outside the cardiac catheterization laboratory have been proposed, but have not uniformly shown success in reducing mortality or in preventing adverse left ventricular remodeling resulting from this condition. The aim of this article is to provide a brief and concise review of the current understanding of the pathophysiology, clinical predictors, and investigations and management of coronary no-reflow phenomenon.

Functional Assessment of Coronary Artery Lesions-Old and New Kids on the Block.

Angiography is inaccurate in assessing functional significance of coronary lesions, and often stenoses deemed severe on angiographic assessment do not restrict coronary blood flow at rest or with maximal dilatation. Angiography-guided revascularization has not shown improvement in hard clinical outcomes in stable ischemic heart disease (SIHD). Most current guidelines for SIHD recommend invasive functional assessment of lesions to guide revascularization if prior evidence of ischemia is not available. There has been several recent advances and development of novel methods in this arena. Various contemporary clinical trials have been undertaken for validation of these indices. Here we review the physiological basis, tools, techniques, and evidence base for various invasive (resting as well as hyperemic) and noninvasive methods for functional assessment of coronary lesions. Left main stenosis, bifurcation lesions, serial stenosis, and acute coronary syndrome each causes unique disequilibrium that may affect measurements and require special considerations for accurate functional assessment.

"Contrecoup" Paravalvular Leak Closure.

Paravalvular aortic regurgitation affects some patients after surgically implanted prosthesis. The number of patients affected is likely to increase with increased utilization of nonsurgical valve replacement techniques. These patients are at increased risk of persistent clinical symptoms often requiring repair. Clinical and procedural outcomes are of importance when performing these procedures and managing these patients. We describe a case where two different leaks around an aortic prosthesis improved with closure of one defect.

Fatal pheochromocytoma crisis precipitated by dobutamine stress echocardiography.

The safety of dobutamine stress echocardiography (DSE) has been demonstrated in multiple studies with a major complication rate of <1%. Specifically, ventricular tachycardia during DSE has a reported incidence of 0.3%, and has been bound to be of no prognostic significance in patients without obstructive coronary artery disease. We report a unique case of fatal pheochromocytoma crisis precipitated by DSE in a patient with heretofore unknown adrenal disease. We are once again reminded that no diagnostic modality is absolutely without risk; however, minimal they might be.

Safe Transcatheter Aortic Valve Replacement in a Patient with a Highly Mobile Aortic Valve Mass.

Some cardiac valve masses may have embolic potential with worrisome consequences. We describe the dilemmas of and solutions for a highly mobile papillary fibroelastoma on the aortic valve in a nonsurgical patient undergoing transcatheter aortic valve replacement. It was performed safely. The potential strategies to minimize the risk of embolization are discussed.

Friedreich's ataxia as a cause of premature coronary artery disease.

Friedreich's ataxia is the most common hereditary neurodegenerative disorder, and more than half of all patients show echocardiographic evidence of cardiomyopathy. Although angina has been reported in these patients, the role of coronary artery disease has previously been dismissed and is therefore underestimated. Premature obstructive coronary disease has rarely been angiographically demonstrated in patients with Friedreich's ataxia. We present an unusual case of a 35-year-old woman with Friedreich's ataxia who presented with intermittent chest pressure associated with dyspnea and diaphoresis. Cardiac catheterization revealed a chronically occluded left circumflex coronary artery and a high-grade stenosis of the left anterior descending coronary artery. A Cypher stent, placed within the left anterior descending artery, left no residual stenosis. This case illustrates the importance of fully investigating anginal symptoms in patients with Friedreich's ataxia, because coronary artery disease is likely underdiagnosed in this population. Early diagnosis may permit aggressive management and may delay the progression to end-stage cardiomyopathy.

Spontaneous left anterior descending coronary artery dissection in a patient with neurofibromatosis.

Neurofibromatosis (NF) is a genetic disorder inherited in an autosomal dominant pattern. Subtypes I and II are the most well recognized, and among these, Type I has associated vasculopathy. Less than 3% of patients have vascular involvement, with the renal artery as the most commonly involved vessel. Dissection and rupture of aneurysms in larger arteries such as the subclavian and the aorta have been previously reported. This is the first reported case of a spontaneous coronary artery dissection in a patient with NF-I. Imperative in the percutaneous treatment of coronary artery dissections is early recognition and proactive decision making. Recognition of a possible association between NF and coronary dissections will further facilitate successful and prompt management of this otherwise rare entity.