Cardiogenic shock temporally associated with COVID-19 vaccination after prior COVID-19 infection: A case report.

The introduction of coronavirus 2019 (COVID-19) vaccination has been an integral force in stopping the spread of COVID-19 across the globe. While reported side effects of vaccination have predominantly been mild, in the last year reports have emerged of myocarditis following the BNT162b2 (Pfizer-BioNtech) and mRNA-1273 (Moderna) vaccinations. The adolescent and young adult population have been the population most reported, with over 1000 cases under review by the Centers for Disease Control (CDC) since April 2021. Here we report a case of a previously healthy 21-year-old male who developed Multisystem Inflammatory Syndrome in Adults (MIS-A) and following the second dose of the Pfizer-BioNtech vaccine. The young male initially presented with fever, leukocytosis with high neutrophil-lymphocyte ratio, severe cardiac illness, and positive COVID-19 nucleocapsid serology, consistent with MIS-A diagnosis. His case was complicated by cardiogenic shock, requiring brief venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. While this report does not detract from the overwhelming benefit of vaccination from COVID-19, clinicians should be aware of this possible relationship in the future.

Cardiac rehabilitation: A class 1 recommendation.

Cardiac rehabilitation, consisting of prescribed exercise and counseling for risk modification, has proven benefits for patients with cardiovascular disease. Nevertheless, rates of referral and use remain low. Efforts to increase program referral and participation are ongoing.

Transfer of patients with suspected acute aortic syndrome.

Patients with acute aortic syndrome (AAS) often require emergent transfer for definitive therapy. The aim of this study was to evaluate the safety of transfer and the ability to optimize hemodynamics in subjects with AAS transported by an aortic network. A total of 263 consecutive patients with suspected AAS transferred to a coronary care unit from March 2010 to June 2012 were included. Transfers were accomplished by the institutional critical care transfer system using ground ambulance (n = 47), helicopter (n = 196), or fixed-wing jet (n = 20) from referring centers directly to the coronary care unit, bypassing the emergency department. The transfer mortality rate was 0%, and the in-hospital mortality rate was 9% (n = 23). Initial systolic blood pressure and heart rate at the time of arrival of the transfer team to the referring hospital were compared with those on arrival to the coronary care unit. The median transfer distance was 66 km (interquartile range 24 to 119), and the median transfer time was 87 minutes (interquartile range 67 to 114). The transfer team achieved significant reductions in systolic blood pressure (from 142 ± 29 to 132 ± 23 mm Hg) (mean difference in systolic blood pressure 10 mm Hg, 95% confidence interval 7 to 14, p <0.0001) and heart rate (from 78 ± 16 to 75 ± 16 beats/min) (mean difference in heart rate 3 beats/min, 95% confidence interval 1 to 4, p <0.0001). In conclusion, these results indicate that patients with AAS can be safely transferred to specialized centers for definitive treatment, and a well-trained critical care transfer team can actively continue to optimize medical management during transit.

Arteriotomy closure device safety after percutaneous coronary intervention in the direct thrombin inhibitor era: a comparative study.

OBJECTIVES: To investigate the safety and risk of vascular complications of arteriotomy closure devices (ACD) with the direct thrombin inhibitor bivalirudin in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: ACDs and manual compression have been shown to have a similar risk of complications in the setting of PCI with heparin ± glycoprotein (GP) IIb/IIIa inhibitor usage. In many centers bivalirudin is becoming the most frequent type of anticoagulation used during PCI. We sought to determine the risk of vascular complications using Angio-Seal, Perclose, and manual compression for groin hemostasis using predominantly bivalirudin. METHODS: Our institution's interventional database retrospectively identified 14,354 consecutive patients undergoing PCI from 2000 to 2008. Patients were grouped by the adjunctive anticoagulation used (bivalirudin vs. heparin + GP IIb/IIIa inhibitors) as well as ACD employed. The incidence of complications was evaluated using multivariable analysis to account for baseline differences between groups. RESULTS: Patients undergoing PCI with adjunctive bivalirudin had significantly fewer complications overall, regardless of closure method (2.9% vs. 8.7%, P < 0.001). The Perclose group had significantly fewer complications than the Angio-Seal and manual compression groups (3.9% vs. 5.6% vs. 9.0%, P < 0.001) respectively; the Angio-Seal group had significantly fewer complications than manual compression. Multivariable analysis also identified age ≥ 65, female gender, BMI ≤ 26, and operator as independent predictors of complications. CONCLUSIONS: The use of adjunctive bivalirudin during PCI was associated with fewer vascular complications. In addition, the Perclose and Angio-Seal devices had significantly fewer complications than manual compression and women ≥ 65 are at highest risk.

Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center.

STUDY OBJECTIVE: Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. METHODS: We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. RESULTS: Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. CONCLUSIONS: The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.

Dual antiplatelet therapy in coronary artery disease: a case-based approach.

Current guidelines support dual antiplatelet therapy with aspirin and clopidogrel (Plavix) in a number of clinical scenarios, ie, in ST-segment-elevation myocardial infarction (MI), non-ST-elevation MI, and percutaneous coronary intervention. The guidelines are based on strong evidence from several large randomized clinical trials over the last 10 years. The authors present several cases to show how to put this evidence into day-to-day clinical practice.