Prognostic Role of Metabolic Exercise Testing in Heart Failure.

Heart failure is a clinical syndrome with significant heterogeneity in presentation and severity. Serial risk-stratification and prognostication can guide management decisions, particularly in advanced heart failure, when progression toward advanced therapies or end-of-life care is warranted. Each currently utilized prognostic marker carries its own set of challenges in acquisition, reproducibility, accuracy, and significance. Left ventricular ejection fraction is foundational for heart failure syndrome classification after clinical diagnosis and remains the primary parameter for inclusion in most clinical trials; however, it does not consistently correlate with symptoms and functional capacity, which are also independently prognostic in this patient population. Utilizing the left ventricular ejection fraction as the sole basis of prognostication provides an incomplete characterization of this condition and is prone to misguide medical decision-making when used in isolation. In this review article, we survey and exposit the important role of metabolic exercise testing across the heart failure spectrum, as a complementary diagnostic and prognostic modality. Metabolic exercise testing, also known as cardiopulmonary exercise testing, provides a comprehensive evaluation of the multisystem (i.e., neurological, respiratory, circulatory, and musculoskeletal) response to exercise performance. These differential responses can help identify the predominant contributors to exercise intolerance and exercise symptoms. Additionally, the aerobic exercise capacity (i.e., oxygen consumption during exercise) is directly correlated with overall life expectancy and prognosis in many disease states. Specifically in heart failure patients, metabolic exercise testing provides an accurate, objective, and reproducible assessment of the overall circulatory sufficiency and circulatory reserve during physical stress, being able to isolate the concurrent chronotropic and stroke volume responses for a reliable depiction of the circulatory flow rate in real time.

Mortality associated with antiarrhythmic medication for atrial fibrillation among patients with left ventricular hypertrophy.

BACKGROUND: Atrial fibrillation (AF) guidelines recommend amiodarone as the preferred antiarrhythmic medication (AAM) in patients with left ventricular hypertrophy (LVH), due to potential pro-arrhythmic risk with other AAM. However, there are limited data to support this assertion. METHODS: We retrospectively analyzed the records of 8204 patients who were prescribed AAM for AF and had transthoracic echocardiogram (TTE) at the multicenter, VA Midwest Health Care Network from 2000 to 2021. We excluded patients without LVH (septal or posterior wall dimension ≤1.4 cm). The primary outcome variable was all-cause mortality during antiarrhythmic therapy or within 6 months after stopping it. Propensity-stratified analyses were performed between amiodarone versus non-amiodarone (Vaughan-Williams Class I and III) AAM. RESULTS: A total of 1277 patients with LVH (mean age 70.2 ± 9.5 years) were included in the analysis. Of these, 774 (60.6%) were prescribed amiodarone. Baseline characteristics of the two comparison groups were similar after propensity adjustment. After a median 1.40 years of follow-up, 203 (15.9%) patients died. Incidence rates per 100 patient-year follow-up was 9.02 (7.58-10.66) for amiodarone and 4.98 (3.91-62.56) for non-amiodarone. In propensity-stratified analysis, amiodarone use was associated with 1.58 times higher risk of mortality (95% CI 1.03-2.44; p = .038). Sub-group analysis in 336 (26.3%) patients with severe LVH showed no difference in mortality (HR 1.41, 95% CI 0.82-2.43, p = .21). CONCLUSION: Among patients with AF and LVH, amiodarone was associated with a significantly higher mortality risk than other AAM.

Agreement of Proximal Thoracic Aorta Size by Two-Dimensional Transthoracic Echocardiography and Magnetic Resonance Angiography.

There is currently a lack of uniformity in methods of aortic diameter measurements across different imaging modalities. In this study, we sought to evaluate the accuracy of transthoracic echocardiography (TTE) in comparison with magnetic resonance angiography (MRA) for the measurement of proximal thoracic aorta diameters. This is a retrospective analysis of 121 adult patients at our institution who had TTE and electrocardiogram  (ECG)-gated MRA performed within 90 days of each other between 2013 and 2020. Measurements were made at the level of sinuses of Valsalva (SoV), sinotubular junction (STJ), and ascending aorta (AA) using leading edge-to-leading edge (LE) convention for TTE and inner-edge-to-inner-edge (IE) convention for MRA. Agreement was assessed using Bland-Altman methods. Intra- and interobserver variability were assessed by intraclass correlation. The average age of patients in the cohort was 62 years, and 69% of patients were male. The prevalence of hypertension, obstructive coronary artery disease, and diabetes was 66%, 20%, and 11%, respectively. The mean aortic diameter by TTE was SoV 3.8 ± 0.5 cm, STJ 3.5 ± 0.4 cm, and AA 4.1 ± 0.6 cm. The TTE-derived measurements were larger than the MRA ones by 0.2 ± 2 mm, 0.8 ± 2 mm, and 0.4 ± 3 mm at the level of SoV, STJ, and AA, respectively, but the differences were not statistically significant. There were no significant differences in the aorta measurements by TTE compared with MRA, when stratified by gender. In conclusion, transthoracic echocardiogram-derived proximal aorta measurements are comparable to MRA measurements. Our study validates current recommendations that TTE is an acceptable modality for screening and serial imaging of the proximal aorta.

COVID-19-Associated Myocarditis: An Evolving Concern in Cardiology and Beyond.

The direct and indirect adverse effects of SARS-CoV-2 infection on the cardiovascular system, including myocarditis, are of paramount importance. These not only affect the disease course but also determine clinical outcomes and recovery. In this review, the authors aimed at providing an update on the incidence of Coronavirus disease-2019 (COVID-19)-associated myocarditis. Our knowledge and experience relevant to this area continues to evolve rapidly since the beginning of the pandemic. It is crucial for the scientific and medical community to stay abreast of current information. Contrasting early reports, recent data suggest that the overall incidence of SARS-CoV-2-associated myocarditis is relatively low, yet infected individuals are at a substantially increased risk. Therefore, understanding the pathophysiology and diagnostic evaluation, including the use of serum biomarkers and imaging modalities, remain important. This review aims to summarize the most recent data in these areas as they relate to COVID-19-associated myocarditis. Given its increasing relevance, a brief update is included on the proposed mechanisms of myocarditis in COVID-19 vaccine recipients.

Fulminant myocarditis following coronavirus disease 2019 vaccination: a case report.

BACKGROUND: The BNT162b2 vaccine received emergency use authorization from the U.S. Food and Drug Administration for the prevention of severe coronavirus disease 2019 (COVID-19) infection. We report a case of biopsy and magnetic resonance imaging (MRI)-proven severe myocarditis that developed in a previously healthy individual within days of receiving the first dose of the BNT162b2 COVID-19 vaccine. CASE SUMMARY: An 80-year-old female with no significant cardiac history presented with cardiogenic shock and biopsy-proven fulminant myocarditis within 12 days of receiving the BNT162b2 COVID-19 vaccine. She required temporary mechanical circulatory support, inotropic agents, and high-dose steroids for stabilization and management. Ultimately, her cardiac function recovered, and she was discharged in stable condition after 2 weeks of hospitalization. A repeat cardiac MRI 3 months after her initial presentation demonstrated stable biventricular function and continued improvement in myocardial inflammation. DISCUSSION: Fulminant myocarditis is a rare complication of vaccination. Clinicians should stay vigilant to recognize this rare, but potentially deadly complication. Due to the high morbidity and mortality associated with COVID-19 infection, the clinical benefits of the BNT162b2 vaccine greatly outweighs the risks of complications.

First Successful LVAD Implantation After BioVentrix Revivent TC Ventricular Reshaping.

The Revivent TC System (BioVentrix Inc, San Ramon, CA) enables a less invasive approach for left ventricular reshaping and scar exclusion in selected patients with ischemic cardiomyopathy. Although the system is designed to improve quality of life and to promote reverse remodeling, patients can still progress to end-stage heart failure requiring advanced therapies. This report describes a case of left ventricular assist device surgery in a patient 16 months after Revivent System implantation. The planning process and surgical technique proved to be complex. This case report can help provide guidance to advanced heart failure teams who encounter patients with the Revivent System who require left ventricular assist device support.

Update on COVID-19 Myocarditis.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.

Sex Differences in Takotsubo Syndrome: A Narrative Review.

Takotsubo syndrome (TTS), or apical ballooning syndrome, is a transient and usually reversible form of cardiac dysfunction. It has classically been described in women with cardiac susceptibility when exposed to emotional or physical stress. Various hypotheses on the pathophysiology of TTS have been suggested, but the underlying mechanism remains unknown. There is increasing recognition of the sex differences in the presentation, triggers, severity, and complications of TTS. A literature review was conducted and found 75 relevant articles on PubMed Cochrane Library, and Google Scholar from 2001 to 2019 regarding TTS. We found remarkable sex differences existed in the underlying triggers, pathophysiology, illness severity, complications, and mortality. However, no sex differences were identified for baseline transthoracic echocardiogram findings, age at presentation, presenting symptoms, recurrence, and treatment approach. Much information regarding TTS remain lacking, but collaboration of national and international registries will be beneficial in addressing these gaps.

Patent foramen ovale and ascending aortic aneurysm causing the platypnea-orthodeoxia syndrome.

Patent foramen ovale (PFO) is present in about 25% of the population. Platypnea-orthodeoxia syndrome (POS), which is dyspnea and hypoxemia in the upright position that is relieved when supine, is a rare manifestation of PFO. We describe a case of a 74-year-old woman who presented with new-onset hypoxia. A PFO and a dilated aorta causing POS were found on workup. Symptoms were resolved after undergoing percutaneous PFO closure. This case highlights the mechanism by which an ascending aortic aneurysm can alter hemodynamics through an existing PFO, leading to symptoms of a previously clinically insignificant PFO, and emphasizes how early recognition of POS allows for appropriate intervention.

Massive pulmonary embolism presenting initially as acute psychosis.

This is a case of a 68-year-old man with Parkinson's disease who was admitted in the psychiatry floor for new-onset aggressive behaviour and hallucinations. On the third day of hospitalisation, he suddenly developed dyspnoea followed by an ECG showing atrial fibrillation with rapid ventricular response. A few seconds later, he went into cardiac arrest; he was resuscitated after multiple rounds of Advanced Cardiovascular Life Support. A transthoracic echo showed hypokinetic and enlarged right ventricle. A CT Chest showed a saddle embolus. Patient was provided with systemic thrombolysis, which led to an improvement in his haemodynamic status. Interestingly, his psychotic symptoms also improved. In this paper, we present and review how pulmonary embolism can be associated with acute psychosis.

Multiple cutaneous and mucosal lesions in a patient with cocaine-levamisole-induced vasculopathy syndrome.

Levamisole is an adulterant found in nearly 70% of cocaine in the United States. The concomitant use of levamisole and cocaine leads to a distinct clinical syndrome that typically manifests as agranulocytosis, leukocytoclastic vasculitis, and elevated antineutrophil cytoplasmic antibody (ANCA) levels. Systemic involvement has also been rarely reported with this syndrome. This is a case of a 51-year-old woman with chronic cocaine use who initially presented with multiple cutaneous ulcerations and was later found to have pulmonary and renal involvement. Infectious workup was unrevealing and autoimmune workup revealed highly elevated levels of perinuclear ANCA. Due to continuous cocaine use despite counseling, the patient was readmitted with worsening pulmonary and renal manifestations requiring initiation of immunosuppressive therapy.

Intensity-Dependent Benefit of Statins in Survival Among Prospective Kidney Transplant Patients.

Statin use in patients listed for in kidney transplant is believed to be beneficial. However, the optimum statin dose for improved survival in this high-risk population is unknown. Our study aimed to determine the impact of prekidney transplant statin dosage on survival postkidney transplant. In this retrospective cohort study, we enrolled patients who underwent kidney transplant from January 2005 to September 2015 at Rush University Medical. Data on the statin use and intensity used before kidney transplant were obtained. The patient population was stratified into 2 groups based on prekidney transplant use of statins. Patients using any form of statin, without regard to the type and dose, were placed in the statin groups, whereas the rest were categorized as the no statin group. The statin group was further classified into low-intensity, moderate-intensity, and high-intensity statin subgroups based on the present atherosclerotic cardiovascular disease definition of statin intensity. The primary outcome was patient survival after kidney transplant. A total of 687 patients had data on statin use before kidney transplant were followed. Median follow-up time was 3.4 years (interquartile range 1.2 to 5.6 years). Multivariate analysis showed that the use of statins prekidney transplant was associated with improved survival postkidney transplant compared with prestatin group (Hazard ratio 0.56, confidence intervals 0.32 to 1.00, p = 0.05). When patients on statins were stratified by statin intensity, Kaplan-Meier survival analysis revealed a significant dose-dependent improvement in survival. Multivariate analysis showed that the relation between statin intensity and survival was maintained even after adjusting for confounder (hazard ratio 0.30, confidence intervals 0.18 to 0.51, p <0.001). In conclusion, our data indicate statistically significant survival benefit in patients receiving high-intensity statin before kidney transplant.

An easy miss: aortic dissection in a 'healthy' male.

Aortic dissection is an uncommon cause of chest discomfort that can be rapidly fatal without early diagnosis and prompt treatment. In this report, we present a man with no risk factors who presented with chest discomfort not typical of a dissection, absent pulse and blood pressure differential and a normal chest radiograph. He eventually was diagnosed with an extensive Type-A aortic dissection. We discuss diagnostic clues, classification of aortic dissection and possible treatment options.