Fingerprinting MINOCA: Unraveling Clues With Quantitative CMR.

In the following case series, we describe the clinical presentation of 2 patients with myocardial infarction with nonobstructive coronary arteries with different underlying pathophysiologic mechanisms. In both scenarios, cardiac magnetic resonance (CMR) imaging provided comprehensive tissue characterization with both conventional parametric mapping techniques and CMR fingerprinting. These cases demonstrate the diagnostic utility for CMR to elucidate the underlying etiology and appropriate therapeutic strategy. (Level of Difficulty: Advanced.).

Case report. Thrombus formation on left atrial appendage clip: surgical exclusion and anticoagulation do not obviate transesophageal echocardiography prior to cardioversion.

Background: The cornerstone treatment for atrial fibrillation (Afib) is based on the prevention of cardioembolism with the use oral anticoagulants, which inherently increase the risk of bleeding. An alternative for these patients corresponds to left atrial appendage (LAA) exclusion/closure techniques such as Atriclip. Cases summary: Patient 1: Seventy-two-year-old female who presented with decompensated heart failure, non ST elevation myocardial infarct, and paroxysmal Afib. She underwent coronary artery bypass graft, MAZE procedure, mitral valve repair, and Atriclip (40 mm). Recurrence of Afib postoperatively led to a precardioversion transesophageal echocardiogram (TEE) which demonstrated a LAA pouch thrombus. Patient 2: Sixty-seven-year-old male who underwent electively mitral and tricuspid valve repairs, MAZE procedure, and Atriclip (35 mm). He had recurrent atrial flutter/Afib postoperatively. He received apixaban in addition to rate control medications, and he was readmitted for precardioversion TEE which also demonstrated a LAA pouch thrombus. Discussion: Atriclip is a stapler exclusion device via epicardial approach which has shown excellent exclusion rates in contemporary data. One of the pitfalls of this technique is the possibility of leaving a LAA remnant stump or pouch that is highly thrombogenic. The optimal timing for stopping anticoagulation and the need for precardioversion echocardiography remain uncertain.

Rilonacept for the treatment of recurrent pericarditis.

INTRODUCTION: Recurrent pericarditis (RP) is a debilitating disease that has an underlying autoinflammatory pathophysiology mediated by cytokine interleukin (IL)-1. Rilonacept, a recombinant dimeric fusion protein that blocks IL-1α and IL-1ß signaling has emerged as a valuable therapeutic option of RP. Rilonacept has been evaluated in Phase 2 and 3 clinical trials and was recently approved for RP treatment. AREAS COVERED: This article reviews available clinical trials assessing the efficacy and safety of rilonacept for the treatment of RP. EXPERT OPINION: Findings from the Rhapsody study) trial suggest that rilonacept represents a promising new therapy for those patients with colchicine resistant or glucocorticoid-dependent disease. Treatment leads to rapid clinical response, with a median resolution of symptoms in 5 days, normalization of C-reactive protein (CRP) in a median of 7 days, and successful weaning from glucocorticoids. This novel therapy also reduces recurrence rates compared with placebo. Rilonacept has also demonstrated a good safety profile, with the most common adverse events including injection-site reactions and upper respiratory tract infections. This anti-IL 1 agent has emerged as an efficacious treatment for RP, with potential use for glucocorticoid-free regimens and as monotherapy. Future trials are needed to explore these treatment options and to clarify the appropriate therapy duration.

Emerging Therapies for Recurrent Pericarditis: Interleukin-1 inhibitors.

Recurrent pericarditis (RP) is a complex inflammatory disorder associated with adverse outcomes and poor quality of life. After the first episode of acute pericarditis, a non-negligible group of patients will fail to achieve complete remission despite treatment and will be challenged by side effects from the chronic use of medications like corticosteroids. The cause of RP remains unknown in the majority of cases, mainly due to a gap in knowledge of its complex pathophysiology. Over the past 2 decades, the interleukin-1 (IL-1) pathway has been uncovered as a key element in the inflammatory cascade, allowing the development of pharmacological targets known as IL-1 inhibitors. This group of medications has emerged as a treatment option for patients with RP colchicine-resistance and steroid dependents. Currently, anakinra and rilonacept, have demonstrated beneficial impact in clinical outcomes with a reasonable safety profile in randomized clinical trials. There is still paucity of data regarding the use of canakinumab in the treatment of patients with RP. Although further studies are needed to refine therapeutic protocols and taper of concomitant therapies, IL-1 inhibitors, continue to consolidate as part of the pharmacological armamentarium to manage this complex condition with potential use as monotherapy. The aim of this review is to highlight the role of IL-1 pathway in RP and discuss the efficacy, safety, and clinical applicability of IL-1 inhibitors in the treatment of RP based on current evidence.

Multimodality imaging in the diagnosis and management of prosthetic valve endocarditis: A contemporary narrative review.

Infective endocarditis is one of the leading life-threatening infections around the world. With the exponential growth in the field of transcatheter interventions and advances in specialized surgical techniques, the number of prosthetic valves and cardiac implantable devices has significantly increased. This has led to a steep rise in the number of cases of prosthetic valve endocarditis (PVE) comprising up to 30% of all cases. Clinical guidelines rely on the use of the modified Duke criteria; however, the diagnostic sensitivity of the modified Duke criteria is reduced in the context of PVE. This is in part attributed to prosthesis related artifact which greatly affects the ability of echocardiography to detect early infective changes related to PVE in certain cases. There has been increasing recognition of the roles of complementary imaging modalities and updates in international society recommendations. Prompt diagnosis and treatment can prevent the devastating consequences of this condition. Imaging modalities such as cardiac computed tomography and 18-fluorodeoxyglucose positron emission tomography/computed tomography are diagnostic tools that provide a complementary role to echocardiography in aiding diagnosis, pre-operative planning, and treatment decision-making process in these challenging cases. Understanding the strengths and limitations of these adjuvant imaging modalities is crucial for the implementation of appropriate imaging modalities in clinical practice.

The Role of False Tendons in Left Ventricular Remodeling and Secondary Mitral Regurgitation After Acute Myocardial Infarction.

BACKGROUND: Left ventricular false tendons (LVFT) are common structures visualized on transthoracic echocardiography (TTE). The present study tested the hypothesis that LVFT, via a possible 'constraint' mechanism, attenuate left ventricular (LV) remodeling and secondary mitral regurgitation after acute myocardial infarction. METHODS: Seventy-one patients admitted to the Coronary Care Unit following an ST-elevation (n = 63) or non-ST-elevation (n = 8) myocardial infarction were analyzed; 29 (41%) had LVFT, and 42 (59%) did not (no-LVFT). All had a TTE and at least 1 follow-up study after revascularization. The χ² analysis, Student's t-test, and Mann Whitney U test were used for the statistical analyses. RESULTS: The mean age (64 vs. 66 years), left ventricular ejection fraction (LVEF) (41% vs. 39%), left ventricular end-diastolic diameter (LVEDd) index (23 mm/m² for both), and prevalence of ≥ moderate secondary/functional mitral regurgitation (MR) (17% vs. 14%) were similar between the LVFT and no-LVFT groups. At 1-year follow-up, there was no significant difference in chamber remodeling amongst the LVFT versus no-LVFT group when assessed by: 1) ≥ 10% decrease in the relative LVEF (24% vs. 26%; p = 0.83); 2) ≥ 10% increase in the LVEDd index (41% vs. 38%, p = 0.98); and, 3) ≥ 10% increase in the LV mass index (48% vs. 41%, p = 0.68). There was no difference in the prevalence of ≥ moderate secondary/functional MR (17% vs. 12%, p = 0.77). Outcomes remained similar when stratifying by LVFT morphology or ischemic territory. CONCLUSIONS: In patients with mild to moderate LV dysfunction and normal chamber size, LVFT do not affect the development of LV remodeling or secondary/functional MR post-myocardial infarction.

Left ventricular pacemaker wire through patent foramen ovale.

A 53-year-old male status post pacemaker placement three months prior for sinus bradycardia presented with worsening dyspnea, holosystolic murmur, and a ventricular-paced right bundle branch block on electrocardiogram. Transesophageal echocardiography demonstrated a pacer wire in the right atrium coursing into the left atrium and ventricle through an undiagnosed patent foramen ovale. The patient underwent surgical repair and repositioning of the pacemaker lead without complication. Although rare, it should be suspected after recent lead placement.

Unicuspid aortic valve: Case series and review.

A unicuspid aortic valve is a very rare valvular lesion. Its physical manifestations vary and are associated with other cardiovascular abnormalities such as aortic stenosis/insufficiency and aortopathy. Echocardiography remains the modality of choice, with computerized tomography or cardiac magnetic resonance used as adjunctive imaging. Herein, we present a case series of three patients with unicuspid aortic valves treated at our institution, with a focus on 2D and 3D echocardiographic imaging.

Structural heart disease: the year in valvular and complex coronary intervention trials.

The need for treatment strategies targeting complex structural heart and obstructive epicardial coronary artery disease (CAD) is rapidly growing. The demographics in referral centers has shifted to an older population with greater co-morbidities and higher risk. Indeed, nearly one quarter of patients in tertiary-care settings have moderate or severe valvular heart disease, and despite a decrease in overall CAD burden in the United States over the past two decades the prevalence of myocardial infarction remains high. The 2019 societal scientific sessions included novel research and landmark presentations on less invasive valvular and safer complex coronary interventions in the aforementioned populations, in hopes of improving patient outcomes and expanding treatment indications. Transcatheter aortic valve replacement (TAVR), percutaneous mitral and tricuspid valve therapy, and complex coronary interventions, were the focus of important clinical trials and registry data. Herein, we provide a select and concise review of the most pivotal studies presented.

Transthoracic versus intra-operative transesophageal echocardiography in right heart assessment.

METHODS: Fifty-four patients who had combined mitral and tricuspid valve surgery were included. Right heart measurements were performed in the TTE apical 4-chamber (A4C) and RV inflow views, and TEE mid-esophageal 4-chamber (ME4C) and transgastric RV inflow views at end-diastole. Spearman correlation coefficients (r) were applied to test for associations between the imaging modalities. RESULTS: The mean age was 65 years and 39% were male. All patients had ≥ moderate tricuspid regurgitation (TR), and a secondary/functional etiology was present in 89%. The median TAd and RV basal (RVd) diameters in the TTE-A4C view measured 37 mm [interquartile range (IQR), 34-44] and 43 mm (IQR, 40-51), respectively. The TTE-A4C TAd strongly correlated with the TEE-ME4C measurement (r=0.72), with an overestimation of 1 mm (IQR, -2 to 4) by TEE (P<0.01). For RVd, the TTE-A4C measurement correlated moderately with the TEE-ME4C view (r=0.61), underestimating the RVd by -1 mm (IQR, -4 to 3.3) (P<0.01). No correlation was observed between TAPSE measured by TTE and TEE (r=0.22, P=0.13). CONCLUSIONS: Intra-operative TEE may reliably quantitate TA and RV size and geometry. The current findings are best interpreted as hypothesis-generating for future validative studies.

Obstructive heart failure with Cardiobacterium hominis infective endocarditis.

We illustrate the progression of Cardiobacterium hominis infective endocarditis in a patient with a bioprosthetic mitral valve and decompensated heart failure secondary to an obstructive septic vegetation.

Transthyretin Cardiac Amyloidosis as Diagnosed by 99mTc-PYP Scanning in Patients with Acute Heart Failure and Preserved Ejection Fraction.

Transthyretin amyloid deposition is present in 17% of autopsies of patients with heart failure and a preserved ejection fraction (HFpEF). Technetium-pyrophosphate scintigraphy (Tc-PYP) is sensitive and specific to diagnose cardiac transthyretin amyloid deposition (ATTR). The prevalence of ATTR by Tc-PYP was evaluated along with echocardiographic parameters in patients with HFpEF. One-hundred consecutive patients with HFpEF, who had Tc-PYP, were retrospectively evaluated. Echocardiographic variables were analyzed to compare patients with positive versus negative ATTR infiltration. Myocardial ATTR was present in 19% of patients. Individuals with ATTR were older with a mean age of 82 ± 7 versus 75 ± 13 years (P = 0.03), had increased left ventricular hypertrophy with the interventricular septum measuring 1.6 (IQR, 1.4-2.0) versus 1.4 (IQR, 1.3-1.6) cm (P = 0.002), had a greater mean left ventricular mass index of 160 ± 50 g/m versus 131 ± 44 g/m (P = 0.01), and a reduced global longitudinal strain measuring -11% (IQR, -9 to -12) versus -12% (IQR, -10 to -16), P = 0.04. The prevalence of ATTR myocardial deposition demonstrated by Tc-PYP in patients with HFpEF is comparable to that of autopsy studies. It is more common in older patients, with increased left ventricular hypertrophy and reduced global longitudinal strain.

A Case of Cephalic Tetanus in an Elderly Patient with Trismus.

We report a case of a 77-year-old woman who presented to the Emergency Room with a three-day history of oral lesions and jaw tightness. Her physical examination was remarkable for the presence of trismus and white ulcers on the visible portion of the tongue. CT head and neck was unremarkable, and she was discharged with empiric treatment for oral candidiasis. She returned two days later with worsening symptoms and subsequently developed tonic-clonic seizures. MRI of the brain and temporomandibular joints were noncontributory. Psychiatry was consulted, and the patient was prescribed olanzapine and mirtazapine for suspected depression with somatization symptoms. She continued to deteriorate despite therapy and developed right lid ptosis and ophthalmoparesis, which led to a presumptive diagnosis of cephalic tetanus. On the 14th day of illness, tetanus immune globulin, metronidazole, and tetanus toxoid vaccine were administered. Despite treatment, the patient died after 24 days of hospitalization. This case illustrates the importance of early recognition of tetanus since successful treatment depends on timely administration of immune globulin.

Thyroid Abscess: Challenges in Diagnosis and Management.

Thyroid abscess is an uncommon infectious pathology. The thyroid is highly resistant to infection due to high iodine content, capsular encasement, and rich vascularity. Acute suppurative thyroiditis represents <1% of thyroid diseases that could potentially become a life-threatening endocrine emergency. A 48-year-old woman with AIDS presented with 3 days of fever, tender neck swelling, and methicillin-resistant Staphylococcus aureus bacteremia. Apart from leukocytosis, initial laboratory values including thyroid function tests were normal. The initial plain computed tomography scan of the neck and ultrasound scan of the neck were inconclusive as well. By day 4, she worsened, and on repeat computed tomography scan of the neck with contrast, multiloculated abscesses in the thyroid and retro pharynx were seen, which needed emergent drainage. Acute suppurative thyroiditis, a rare disease, occurs in patients with either preexisting disorders of the thyroid or in the immunocompromised. The most common pathogen is Staphylococcus aureus. In our case, we highlight the fact that initial imaging may be negative in the early stages of acute suppurative thyroiditis and lead to an erroneous diagnosis of subacute thyroiditis. There are less than 5 cases of methicillin-resistant Staphylococcus aureus suppurative thyroiditis reported.

Myocardial Infarction Presenting as Ear Fullness and Pain.

Acute coronary syndrome usually presents with retrosternal chest pain, nausea, vomiting, sweating, and jaw and arm pain. Some patients only present with neck, epigastric, or ear discomfort. A 47-year-old male with a history of hypertension and coronary artery disease presented to the emergency department complaining of bilateral otalgia. He never felt chest pain, jaw pain, nausea, diaphoresis, or shortness of breath. He had a history of 2 acute coronary events and had a stress test 2 months prior to admission, which was unremarkable. The initial electrocardiography was sinus rhythm with Q-waves in the inferior leads and nonspecific ST changes in the lateral leads. His troponin on admission was normal but subsequently elevated to 20.00 mg/mL after 24 hours. He underwent left heart catheterization, which found significant occlusive disease of the second and fourth obtuse marginal branches and 2 drug-eluting stents were placed. His ear pain resolved soon after cardiac catheterization. The pathophysiology of this referred pain is thought to be related to the neuroanatomy of the nerves innervating the heart and ear. The auricular nerve branch of the vagus nerve supplies the inner portion of the external ear. Only a few cases with the complaint of otalgia have been reported. Patients were older, more frequently women, and with diabetes or heart failure. Clinicians should be aware of the atypical presentation of angina that may be life-threatening cardiac ischemia. Ear pain and fullness could be the sole presenting symptom in a patient with acute coronary syndrome.

Fatal Pulmonary Embolism in the Setting of Immune Reconstitution Inflammatory Syndrome Attributed to Ovarian Tuberculosis.

In developed countries, tuberculosis remains a health care challenge due to human immunodeficiency virus (HIV) and immigration from endemic regions. The Centers for Disease Control and Prevention reported 9557 new cases in 2015, with extrapulmonary involvement in 20.2% of the cases. We present a 33-year-old woman from Cape Town, South Africa, who developed abdominal pain and fever while working on a cruise ship. She sought medical where she underwent computed tomography of her chest, abdomen, and pelvis with findings suggestive of pulmonary tuberculosis and an 8.9-cm pelvic mass. HIV testing was positive and the patient was started on antiretroviral therapy. Bronchoscopy confirmed the presence of acid-fast bacilli, and she was started on rifampin, isoniazid, pyrazinamide, and ethambutol. She remained persistently febrile, raising suspicion for immune reconstitution inflammatory syndrome. However, despite empiric antibiotics, the patient remained persistently febrile, tachycardic, and on day 10 of admission she went into ventricular fibrillation and expired. Autopsy revealed an occlusive thrombus in the left main pulmonary artery in addition to necrotizing granulomata in multiple organs and bilateral tubo-ovarian abscesses. Postmortem cultures for were positive for Mycobacterium tuberculosis, all consistent with disseminated Mycobacterium tuberculosis. Although previous reports underscore the association between tuberculosis and hypercoagulability, the exact mechanism remains unknown. In this article, we report a case of disseminated tuberculosis complicated by bilateral tubo-ovarian abscesses with fatal pulmonary thrombus formation.