Successful drainage of periaortic graft abscess and transcatheter aortic valve replacement in the same setting-A hybrid approach.

PRESENTATION: 81-year-old man with a history of Bio-Bentall surgery presented to the emergency department with fever, chills and back pain. Initial physical examination was inconclusive apart from sudden onset of delirium. INVESTIGATION: Elevated white blood cells, anemia, and neutrophilia. Further studies revealed gram-positive cocci on the initial blood culture, which was then confirmed to be Methicillin Sensitive Staph Aureus bacteremia. Subsequently, a transesophageal echocardiography showed a periaortic abscess, moderate aortic regurgitation and severe aortic stenosis with no evidence of endocarditis. MANAGEMENT: Antibiotics were started and urgent abscess drainage was planned. In a hybrid operative setting, a multidisciplinary team of cardiology, and cardiac surgery managed the periaortic graft abscess drainage through a median sternotomy and transcatheter aortic valve replacement. Postoperatively, the complications included bradycardia, and right heart failure. Six-week course of IV Rifampin, Probenecid, and Cefazolin was initiated, and patient was to remain on lifelong Cefadroxil. CONCLUSION: A hybrid approach should be considered for patients with high morality risks in the field of cardiovascular medicine as it offers the best available combination of treatments.

Cardiovascular Outcomes in Nova Scotia During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: This study sought to determine the impact of the COVID-19 pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease. METHODS: This is a population-based cohort study performed in the province of Nova Scotia, Canada (population 979,499), between the pre-COVID (March 1, 2017-March 16, 2020) and in-COVID (March 17, 2020-December 31, 2020) periods. Adult patients (age ≥ 18 years) with new-onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included the following: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest. RESULTS: In the first month of the in-COVID period, emergency department visits (n = 51,750) for cardiac symptoms decreased by 20.8% (95% confidence interval [CI] 14.0%-27.0%, P < 0.001). Cardiovascular hospitalizations (n = 20,609) declined by 48.1% (95% CI 40.4% to 54.9%, P < 0.001). The in-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95% CI 10.1%-118%, P = 0.013). A decline of 20.4%-44.0% occurred in cardiovascular surgical/interventional procedures. The number of out-of-hospital cardiac arrests (n = 5528) increased from a monthly mean of 115 ± 15 to 136 ± 14, beginning in May 2020. Mortality for ambulatory patients awaiting cardiac intervention (n = 14,083) increased from 0.16% (n = 12,501) to 2.49% (n = 361) in the in-COVID period (P < 0.0001). CONCLUSIONS: This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during the COVID-19 period, in an area with a low burden of COVID-19. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms, and policy for delivery of cardiovascular care.

CONTEXTE: Cette étude visait à déterminer les répercussions de la réponse à la pandémie de COVID-19 sur la prestation des soins de santé et son incidence sur les résultats obtenus par les patients atteints d'une maladie cardiovasculaire. MÉTHODOLOGIE: Il s'agit d'une étude de cohorte représentative de la population réalisée dans la province de la Nouvelle-Écosse, au Canada (population de 979 499 habitants), entre la période précédant le début de la pandémie de COVID-19 (du 1er mars 2017 au 16 mars 2020) et la période de pandémie (du 17 mars 2020 au 31 décembre 2020). Des patients adultes (âge ≥ 18 ans) atteints d'une maladie cardiovasculaire préexistante ou d'apparition récente ont été inclus pour la comparaison entre les périodes. Les principaux paramètres d'évaluation comprenaient les visites ou hospitalisations dans un service d'urgences cardiovasculaires, la mortalité et l'arrêt cardiaque en milieu extrahospitalier. RÉSULTATS: Au cours du premier mois de la période de pandémie, les visites aux services des urgences (n = 51 750) pour des symptômes cardiaques ont diminué de 20,8 % (intervalle de confiance [IC] à 95 % : 14,0 % ­ 27,0 %, p < 0,001). Les hospitalisations en raison d'un événement cardiovasculaire (n = 20 609) ont décliné de 48,1 % (IC à 95 % : 40,4 % ­ 54,9 %, p < 0,001). Le taux de mortalité hospitalière parmi les patients admis dans des établissements de soins secondaires a augmenté de 55,1 % (IC à 95 % : 10,1 % ­ 118 %, p = 0,013). Une baisse de 20,4 à 44,0 % du nombre d'interventions chirurgicales ou interventionnelles visant à prendre en charge un événement cardiovasculaire a également été enregistrée. Le nombre d'arrêts cardiaques survenus en milieu extrahospitalier (n = 5 528) est passé d'une moyenne mensuelle de 115 ± 15 à 136 ± 14, à compter de mai 2020. La mortalité des patients ambulatoires en attente d'une intervention cardiaque (n = 14 083) a augmenté, passant de 0,16 % (n = 12 501) à 2,49 % (n = 361) pendant la période de pandémie (p < 0,0001). CONCLUSIONS: Cette étude révèle une augmentation de la morbidité et de la mortalité cardiovasculaires durant le maintien des restrictions liées à la COVID-19 dans une région où le fardeau associé à cette maladie est faible. À mesure que le système de santé se rétablit ou affronte les vagues subséquentes de COVID-19, ces résultats devraient éclairer les communications au public concernant les symptômes cardiovasculaires et orienter la politique de prestation de soins cardiovasculaires.

Right ventricular echocardiographic parameters for prediction of proximal right coronary artery lesion in patients with inferior wall myocardial infarction.

BACKGROUND: Classifying the location of an occlusion in the culprit artery during ST-elevation myocardial infarction is important for risk stratification to optimize treatment. OBJECTIVES: To compare the validity of echocardiographic parameters assessing right ventricular (RV) function for the prediction of proximal right coronary artery (RCA) lesion in patients with inferior wall myocardial infarction. METHODS: The study included 76 patients after their first episode of acute inferior myocardial infarction with significant RCA lesion (43 patients with proximal RCA stenosis and 33 patients with distal RCA stenosis). Full echocardiographic examination was done before revascularization, including RV dimension, tricuspid annular plane systolic excursion, and tissue Doppler imaging of RV free wall at the level of the tricuspid annulus and recording the following variables: peak systolic velocity (Sm), peak early diastolic velocity, peak late diastolic velocity, ejection time (ET), isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), and myocardial performance index (MPI), which was calculated as (MPI = IVRT + IVCT/ET). RESULTS: Patients with proximal RCA showed significantly lower Sm (10.44 ± 2.61 cm/s vs. 12.11 ± 2.94 cm/s, p = 0.013) and shorter ET (224.18 ± 49.96 ms vs. 280.90 ± 46.12 ms, p = 0.001). While IVRT, IVCT, and MPI were significantly higher (95.25 ± 19.22 ms vs. 68.48 ± 12.77 ms, p = 0.001; 81.62 ± 23.59 ms vs. 60.90 ± 17.38 ms, p = 0.001; and 0.82 ± 0.222 vs. 0.47 ± 0.10, p = 0.001, respectively) when compared with patients with distal RCA stenosis. Multiple regression analysis including (tricuspid annular plane systolic excursion, Sm, and MPI) showed that the most independent predictors for proximal RCA lesions were MPI (p = 0.0001). The receiver operator characteristic curve for MPI showed areas under the curve of 97% and a confidence interval of 93%. A cut-off value of 0.58 for MPI had a sensitivity of 95% and specificity of 97% for the diagnosis proximal RCA. CONCLUSIONS: The most independent predictors for proximal RCA lesion is MPI.