Gas in the myocardium: a fatal presentation of Clostridium perfringens: a case report.

Background: Clostridium perfringens is a well-known cause of gas gangrene with a very high mortality rate. Multiple cases of internal organs have been reported in the literature; however, non-traumatic spontaneous gas gangrene due to C. perfringens with solely cardiac involvement in a patient without any risk factors has not been reported before. Case Summary: A 52-year-old male presented to the emergency department with chest pain and exertional dyspnoea for three days. The patient was haemodynamically stable initially, and the physical examination was unremarkable. Initial laboratory workup revealed elevated D-dimer and troponin levels. Computerized tomography (CT) of the chest was negative for pulmonary embolism but showed a hypodense focus in the cardiac silhouette. Acute coronary syndrome protocol was initiated; however, invasive cardiac workup was negative. The patient had rapid clinical deterioration with development of respiratory failure, shock, and multiorgan failure within 24 h. A transesophageal echocardiogram demonstrated an abnormal echogenic focus, corresponding to CT chest area. Despite aggressive treatment, the patient passed away within 36 h. Later, the patient's blood culture grew C. perfringens. A limited autopsy showed an abscess cavity in the interventricular septum, pathology of which revealed acute myocarditis and fibrinous pericarditis. Discussion: Unlike other reported cases of C. perfringens with cardiac abscess, our patient had no known risk factors, and no other organs were involved. We conclude from this case that an air focus on the CT scan in the myocardium can be suggestive of a spontaneous gas gangrene of the myocardium, and the patients should be treated accordingly.

Mycobacterium chimaera lung infection and empyema in a patient without cardiopulmonary bypass.

Mycobacterium chimaera is a nontuberculous mycobacterium that belongs to the Mycobacterium avium complex. Invasive infections are very rare and have been associated with contaminated heater-cooler water systems used during cardiopulmonary bypass. There is usually a long latency period and patients have nonspecific symptoms that can result in a delayed diagnosis or misdiagnosis. We report a case of M. chimaera infection in a man who presented with worsening shortness of breath and was found to have pleural effusion. The patient did not have any history of cardiopulmonary bypass surgery, which raises concerns about community spread of this rare infection and needs further investigation in the general population. Furthermore, he had a history of sarcoidosis and was on immunosuppressive medications, which might suggest that immunosuppressed patients can acquire this infection without the described risk factors.

Heart in a shell-a cascade of classical findings: a case report.

Background: Idiopathic chronic constrictive pericarditis (CP) is an uncommon yet very important clinical entity as prompt diagnosis and early treatment are affiliated with improved outcomes. We describe an uncommon case of CP with a series of textbook findings and received successful treatment with surgical pericardiectomy (SP). Case summary: A 58-year-old male presented to the emergency department with exertional dyspnoea and anasarca. The past medical history was negative for infections like tuberculosis, viral, etc., connective tissue disease, prior cardiac surgery, human immunodeficiency virus, or any radiation therapy. The vital signs were within normal limits except mild hypoxia while the physical examination was consistent with congestive heart failure. Further investigations with laboratory testing, imaging with chest X-ray, computed tomography, echocardiogram, and invasive study with right heart catheterization were all consistent with idiopathic chronic CP. The patient underwent successful SP with significant improvement in clinical condition. Discussion: This case highlights the classical signs and symptoms along with important diagnostic features of CP. It is uncommon to see all the classical features of CP in one patient as described in the above case. Familiarity with these findings is crucial to make the diagnosis as early treatment is affiliated with improved outcomes.

Systematic Review and Meta-Analysis: Can We Compare Direct Oral Anticoagulants to Warfarin in Patients With Atrial Fibrillation and Bio-Prosthetic Valves?

Background There are no clear consensus guidelines on the indications and types of anticoagulation therapies in patients with bio-prosthetic valves either with concomitant atrial fibrillation (AF) or sinus rhythm. In our meta-analysis, we assessed the safety and efficacy of DOACs as compared to the standard treatment with warfarin in patients with AF and bioprosthetic valves. Methods We included randomized controlled trials (RCTs), cohort studies in the English language, and studies reporting patients with valvular heart disease that included bioprosthetic valvular disease. A systematic literature review using Embase, PubMed, and Web of Science was performed using the terms "Direct Acting Oral Anticoagulant," "Oral Anticoagulants," "Non-Vitamin K Antagonist Oral Anticoagulant," "Atrial Fibrillation," "Bioprosthetic Valve" for literature published prior to January 2021. Extraction of data from included studies was carried out independently by three reviewers from Covidence. We assessed the methodical rigor of the included studies using the modified Downs and Black checklist. Results Four RCTs and one observational study (n=1776) were included in our study. A random-effect model using RevMan (version 5.4; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for data analysis. The pooled data showed that there was a non-significant reduction in the incidence of stroke and systemic embolism in the patients taking DOACs as compared to warfarin (HR 0.69; 95% CI, 0.29, 1.67; I2 = 50%). The incidence of major bleeding was lower in the DOACs group; the difference was statistically significant (HR 0.42; 95% CI, 0.26, 0.67; I2 = 7%). The difference was not statistically significant for all-cause mortality in both groups (HR 1.24; 95% CI, 0.91, 1.67; I2 = 0%). Conclusion Our results showed that there was no difference in the outcomes of stroke and systemic embolism between DOACs and warfarin but there were statistically significantly lower major bleeding events. We conclude that larger clinical trials are needed to assess the true safety and efficacy of DOACs in patients with AF and bioprosthetic valves.

A Giant Right-Heart Thrombus-in-Transit in a Patient with COVID-19 Pneumonia.

BACKGROUND Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to more than 200 countries across the world. Studies have shown that patients with COVID-19 are prone to thrombotic disease resulting in increased mortality. We present a case of COVID-19 pneumonia in a warehouse worker with a giant thrombus-in-transit involving the right ventricle and tricuspid valve. We also describe the associated diagnostic and therapeutic challenges. CASE REPORT A 54-year-old man with recent COVID-19 exposure presented with fever, cough, dyspnea, and syncope and was found to be in hypoxic respiratory failure requiring supplemental oxygen. The clinical course deteriorated with worsening respiratory failure and septic shock, requiring mechanical ventilation and pressor support. Further evaluation revealed a positive nasopharyngeal swab for SARS-CoV-2 and an S1Q3T3 pattern on electrocardiogram. A bedside transthoracic echocardiogram was performed due to clinical deterioration and hemodynamic instability, which showed a large thrombus-in-transit through the tricuspid valve into the right ventricle. The patient was treated with low-molecular-weight heparin, hydroxychloroquine, azithromycin, and supportive care. A repeat echocardiogram after 1 week did not show any thrombus. The patient slowly improved over the following weeks but required tracheostomy due to prolonged mechanical ventilation. He was discharged on oral anticoagulation. CONCLUSIONS This case highlights the presence of significant COVID-19-related hemostatic disturbances and the importance of associated diagnostic and therapeutic challenges. A bedside echocardiogram can provide valuable information in patients with suspected high-risk pulmonary embolism and hemodynamic instability. Early diagnosis by keeping a high index of suspicion and prompt treatment is vital to avoid adverse outcomes and increased mortality.

Inspiratory Muscle Training in Patients With Heart Failure With Preserved Ejection Fraction: A Meta-Analysis.

Objectives To explore the role of inspiratory muscle training (IMT) in improving cardiorespiratory fitness of stable heart failure with preserved ejection fraction (HFpEF) patients. Background There is a paucity of data on the role of IMT in patients with HFpEF. HFpEF is a growing problem in the developed world, especially in the aging population. Methods We conducted a systematic literature search for English studies in PubMed, EMBASE, and Cochrane Central Register of Controlled Trials. We searched databases using terms relating to or describing breathing exercise, IMT, and HFpEF. RevMan 5.4 (The Cochrane Collaboration, 2020) was used for data analysis, and two independent investigators performed literature retrieval and data extraction. Results We identified three randomized controlled trials (RCTs) and one prospective study on the role of IMT in HFpEF. We calculated the pooled mean difference of peak oxygen consumption (Peak VO2) and six-min walk distance (6MWD) between the IMT and standard care (SC) groups. Our meta-analysis showed that compared with SC, IMT could significantly improve peak VO2 with a mean difference (MD) of 2.82 ml/kg/min, 95% CI [1.90, 3.74] P < 0.00001 and improve 6MWD with MD of 83.97 meters, 95% CI [59.18, 108.76] P< 0.00001 to improve cardiorespiratory fitness at 12 weeks of IMT and improve peak VO2 with MD of 2.18 ml/kg/min, 95% CI [0.38, 3.99] P < 0.00001 at 24 weeks of therapy. Conclusion IMT should be further studied as a possible treatment option to improve cardiorespiratory fitness for patients with stable HFpEF.