Secundum Atrial Septal Defect Closure via the Transhepatic Approach in a Patient With Situs Ambiguus and a Left-Sided Inferior Vena Cava.

Secundum atrial septal defect (ASD) is the most common type of ASD. Symptoms including dyspnea on exertion usually manifest in the third and fourth decade of life. The transcatheter closure is the treatment of choice for secundum ASD. The transfemoral venous approach has been the mainstay. However, this approach can be challenging or impossible in patients with congenital absence or interruption of the inferior vena cava (IVC). The latter has been reported in patients with situs ambiguus and inversus. In this patient population, other forms of venous access such as the transjugular or transhepatic approach are used. We present a unique case of symptomatic secundum ASD in a patient who was incidentally found to have situs ambiguus with a left-sided intact IVC. An initial attempt at the ASD closure via the transfemoral approach was unsuccessful due to acute angulation. A repeat attempt was successful via the transhepatic approach with the guidance of real-time ultrasound, transesophageal echocardiogram, and the involvement of an interventional radiologist. The procedure was well tolerated without any complications. Repeat transthoracic echocardiogram with agitated saline the day after the procedure was negative for interatrial shunting.

COVID-19 cardiac arrest due to Prinzmetal's angina in a previously normal heart.

In COVID-19 patients who develop sudden ST elevations it is necessary to consider cardiac causes other than myocardial infarction, such as coronary vasospasm.

ST-segment elevation in patients presenting with COVID-19: case series.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the now pandemic disease, coronavirus disease (COVID-19). A number of reports have emerged suggesting these patients may present with signs and symptoms consistent with ST-segment elevation myocardial infarction without coronary artery occlusion. CASE SUMMARY: We report an international case series of patients with confirmed COVID-19 infection who presented with suspected ST-segment elevation myocardial infarction. Three patients with confirmed COVID-19 presented with electrocardiogram criteria for ST-segment elevation myocardial infarction. No patient had obstructive coronary disease at coronary angiography. Post-mortem histology in one case demonstrated myocardial ischaemia in the absence of coronary atherothrombosis or myocarditis. DISCUSSION: Patients with COVID-19 may present with features consistent with ST-segment elevation myocardial infarction and patent coronary arteries. The prevalence and clinical outcomes of this condition require systematic investigation in consecutive unselected patients.

SARS-CoV-2 Infects Human Engineered Heart Tissues and Models COVID-19 Myocarditis.

There is ongoing debate as to whether cardiac complications of coronavirus disease-2019 (COVID-19) result from myocardial viral infection or are secondary to systemic inflammation and/or thrombosis. We provide evidence that cardiomyocytes are infected in patients with COVID-19 myocarditis and are susceptible to severe acute respiratory syndrome coronavirus 2. We establish an engineered heart tissue model of COVID-19 myocardial pathology, define mechanisms of viral pathogenesis, and demonstrate that cardiomyocyte severe acute respiratory syndrome coronavirus 2 infection results in contractile deficits, cytokine production, sarcomere disassembly, and cell death. These findings implicate direct infection of cardiomyocytes in the pathogenesis of COVID-19 myocardial pathology and provides a model system to study this emerging disease.

SARS-CoV-2 Infects Human Engineered Heart Tissues and Models COVID-19 Myocarditis.

Epidemiological studies of the COVID-19 pandemic have revealed evidence of cardiac involvement and documented that myocardial injury and myocarditis are predictors of poor outcomes. Nonetheless, little is understood regarding SARS-CoV-2 tropism within the heart and whether cardiac complications result directly from myocardial infection. Here, we develop a human engineered heart tissue model and demonstrate that SARS-CoV-2 selectively infects cardiomyocytes. Viral infection is dependent on expression of angiotensin-I converting enzyme 2 (ACE2) and endosomal cysteine proteases, suggesting an endosomal mechanism of cell entry. After infection with SARS-CoV-2, engineered tissues display typical features of myocarditis, including cardiomyocyte cell death, impaired cardiac contractility, and innate immune cell activation. Consistent with these findings, autopsy tissue obtained from individuals with COVID-19 myocarditis demonstrated cardiomyocyte infection, cell death, and macrophage-predominate immune cell infiltrate. These findings establish human cardiomyocyte tropism for SARS-CoV-2 and provide an experimental platform for interrogating and mitigating cardiac complications of COVID-19.

Atrial Septal Defect with Eisenmenger Syndrome: A Rare Presentation.

Atrial septal defects (ASDs) are common congenital heart defects (CHD). The clinical course in patients without closure of the ASD is associated with significant morbidity and mortality in advanced age. A small percentage of patients may develop pulmonary arterial hypertension (PAH) due to left to right shunting that impacts morbidity and mortality. Advances in prenatal screening and fetal echocardiography have allowed timely interventions. Nonetheless, some patients still may be diagnosed with ASD in adulthood as an incidental finding or presenting with clinical symptoms such as shortness of breath from right heart failure. We report a case of an adult female presenting with shortness of breath due to ASD causing PAH with Eisenmenger physiology.

QT Independent Ventricular Tachycardia Induced by Arsenic Trioxide.

Arsenic trioxide (ATO) is commonly known to cause QT prolongation with resultant ventricular tachycardia (VT). VT, independent of QT prolongation, can be a complication of ATO. We present a 46-year-old female who received ATO and during her hospital course had intermittent nonsustained VT. All usual causes of VT were considered including reduced EF < 35%, ischemia, electrolyte abnormalities, medications, and genetic polymorphisms; however, no specific cause was found. After stopping therapy, the episodes of nonsustained VT ceased indicating that there is an association between ATO and VT.

Manifestation of non-ST elevation myocardial infarction due to hyperthyroidism in an anomalous right coronary artery.

INTRODUCTION: Anomalous origin of the right coronary artery (RCA) from the left coronary cusp of the aorta is a moderately rare but potentially life-threatening incident. Myocardial infarction (MI) and sudden cardiac death have been described with this anomaly, especially in those who engage in excessive exercise. However, this case study shows this incidence in association with hyperthyroidism. CASE DESCRIPTION: A previously healthy 51-year-old female with history of hypothyroidism presented with acute onset chest pain for 1 day. Patient's electrocardiogram was normal, however, she had elevated troponins and given her typical chest pain, she was diagnosed with acute coronary syndrome (ACS). The patient had been on levothyroxine and was found to have a subnormal thyroid-stimulating hormone level suggesting hyperthyroidism. Echocardiogram was normal. Coronary angiogram showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva and no evidence of atherosclerosis. A coronary computed tomography angiogram was done confirming this finding and showed a slit-like deformity of the coronary ostium with at least 50% luminal stenosis. The patient was referred to a cardiothoracic surgeon for potential coronary artery bypass graft. DISCUSSION: This case illustrates a rare presentation of ACS due to hyperthyroidism in an anomalous RCA. MI is a rare manifestation of hyperthyroidism, but in combination with an anatomical defect, it can potentiate adverse outcomes. The mechanisms by which thyroid hormones influence cardiovascular hemodynamics are by causing a hyperdynamic circulatory state, increasing myocardial oxygen demand, and increasing the risk of coronary vasospasm. The combination of anatomic and metabolic defects is what likely precipitated this patient's outcome.

Three-dimensional echocardiographic assessment of a serpiginous ventricular septal defect.

Ventricular septal defects are one of the most common congenital heart defects that either exist alone or coexist with other complex congenital heart diseases. With 3-dimensional echocardiography, exact 3-dimensional shape, size, location, and course of any ventricular septal defects can be evaluated very thoroughly. We are reporting a comprehensive assessment of a complex ventricular septal defect using 3-dimensional echocardiography and longitudinal strain analysis.

Routine versus selective functional testing after percutaneous coronary intervention in patients with diabetes mellitus.

Patients with diabetes mellitus who undergo percutaneous coronary intervention (PCI) have higher rates of restenosis and a poorer prognosis than patients without diabetes. The American College of Cardiology/American Heart Association guidelines on exercise testing suggest that patients with diabetes may benefit from routine post-PCI functional testing (FT). To explore this issue, we examined the functional capacity, quality of life, event rates and procedural outcomes among 61 patients with diabetes enrolled in the Aggressive Diagnosis of Restenosis (ADORE) trial. All patients were randomized to either routine FT or selective FT and were followed for a period of 9 months. Patients with diabetes randomized to routine FT had a higher composite clinical event rate than those randomized to the selective FT strategy. Procedural rates did not differ significantly between the two groups. These results suggest that routine post-PCI FT in patients with diabetes is of little clinical value.

Myocardial laser revascularization for the treatment of end-stage coronary artery disease.

Myocardial laser revascularization is a novel therapeutic technique aimed at delivering oxygenated blood via a series of channels to the ischemic regions of the heart. These channels may be created surgically or via a less invasive percutaneous approach. In patients with end-stage coronary artery disease, both transmyocardial laser revascularization (TMR) and percutaneous myocardial laser revascularization (PMR) have been associated with a reduction in symptoms, improved exercise tolerance, and enhanced quality of life. However, the mechanism of action of laser therapy is incompletely understood, the results of objective cardiac perfusion measurements are inconclusive, and multiple randomized trials have failed to demonstrate an increase in survival. In addition, the positive results seen in TMR trials have been questioned because of a lack of blinding, raising the possibility that the benefit may have been due to the placebo effect. Finally, two recent sham-controlled, randomized clinical trials of PMR have not shown any benefit of the procedure, but instead have highlighted the important role of the placebo effect in the response to PMR. Further research is, therefore, needed to elucidate the value of myocardial laser revascularization.