Unmasking a Silent Threat: Office-Based Diagnosis of an Ascending Aortic Dissection With Transthoracic Echocardiography.

Type A aortic dissection (TAAD) is a potentially life-threatening diagnosis that can present with elusive symptomatology. A high degree of clinical suspicion is necessary for prompt diagnosis and management. We describe a case of a transthoracic echo (TTE) in a non-suspicious clinic patient diagnosed with TAAD. A 66-year-old Caucasian male presented for a routine clinic visit with one episode of acute severe chest pain. An echocardiogram was ordered for further workup of hypertension and chest discomfort. The echocardiogram demonstrated an ejection fraction of 60% without significant valvular abnormalities. There was suspicion of aortic pathology, which required multiple attending to review the images. The final interpretation was TAAD with a thrombus present in the false lumen. The patient then presented to the Emergency Department. A computed tomographic angiography was performed, which subsequently confirmed the TAAD. The patient was admitted to the cardiovascular ICU and ultimately underwent a successful repair of the dissection. The patient had an unremarkable post-operative course and was ultimately discharged home. Our case demonstrated a diagnosis of TAAD by office-based TTE as the original imaging modality. While this was unconventional, a TAAD should remain on the differential diagnosis when being ordered for the patient's with uncontrolled hypertension with chest pain as a presenting symptom.

Clinical and Electrophysiological Outcomes of Left Bundle Area Pacing Compared to Biventricular Pacing: An Updated Meta-analysis.

Left bundle branch area pacing (LBBAP) is a novel pacing strategy that uses the conduction system distal to the left bundle branch block level for direct activation of the left bundle and right ventricular myocardium. Our meta-analysis compared the structural, electrophysiological, clinical, and procedural outcomes of LBBAP and biventricular pacing (BVP). The meta-analysis included two randomized controlled trials and showed significant reductions in the left ventricular (LV) systolic and diastolic volumes with LBBAP compared to BVP, together with statistically significant reductions in the QRS duration, New York Heart Association (NYHA) functional class, and heart failure (HF) hospitalizations. The fluoroscopic time was also significantly shorter in the LBBAP group. However, no significant change in the LV ejection fraction was noted. Procedural complications were slightly higher in the LBBAP group, albeit not to a statistically significant degree. Our findings suggest that LBBAP may be a superior alternative to standard BVP in improving the structural, electrophysiological, and clinical components of cardiomyopathy, including the NYHA class and HF hospitalizations. LBBAP is a more physiological pacing strategy that results in normal ventricular activation and may be a viable alternative to BVP for cardiac synchronization therapy.

Substance Use Disorders (SUDs) and Risk of Cardiovascular Disease (CVD) and Cerebrovascular Disease (CeVD): Analysis of the Nationwide Inpatient Sample (NIS) Database.

BACKGROUND:  Substance use continues to be on the rise in the United States and has been linked to new onset cardiovascular diseases (CVDs) and cerebrovascular disorders (CeVDs). We aimed to study the association between the types of substance use disorders (SUDs) with specific subtypes of CVDs and CeVDs among hospitalized patients using the National Inpatient Sample (NIS) Database. METHODS:  A retrospective study of the NIS database (2016-2017) using the ICD-10-CM codes was performed. The hospitalizations with a secondary diagnosis of SUDs were identified. Weighted univariate analysis using the Chi-square test and multivariate survey logistic regression analysis was performed to evaluate for the incidence, prevalence, and odds of association between vascular events and SUDs. RESULTS:  There were a total of 58,259,589 hospitalizations, out of which 21.42% had SUDs. SUDs were more common in the younger age group of 18-50, males, and the lower median household income group. We found a significant association of acute ischemic stroke (AIS) with amphetamine dependence (adjusted odds ratio, aOR 1.23, 95% confidence interval, CI 1.14-1.33), cocaine-related disorders (1.17, 1.12-1.23), and nicotine dependence (1.42, 1.40-1.43). There was a significant association between intracerebral hemorrhage with amphetamine dependence (2.58, 2.26-2.93), cocaine-related disorders (1.62, 1.46-1.79), and alcohol-related disorders (1.35, 1.01-1.82). The association of subarachnoid hemorrhage (SAH) was noted to be higher with amphetamine dependence (1.82, 1.48-2.24) and nicotine dependence (1.47, 1.39-1.55). The patients with nicotine dependence had greater odds of having a myocardial infarction (1.85, 1.83-1.87), those with cocaine-related disorders had higher odds of having angina pectoris (2.21, 1.86-2.62), and patients with alcohol-related disorders had higher odds of developing atrial fibrillation (1.14, 1.11-1.17) in comparison to non-SUDs. CONCLUSION:  Our study demonstrates the variability of CVD and CeVD in patients hospitalized for SUD. Findings from our study may help promote increased awareness and early management of these events. Further studies are needed to evaluate the specific effects of frequency and dose on the incidence and prevalence of CVD and CeVD in patients with SUD.

COVID-19 and Cardiomyopathy in African Americans: An Early Single-Center Experience.

Introduction The 2019 coronavirus pandemic has taken a toll on our society. Although most patients report minimal symptoms, a small proportion of patients have reported significant respiratory symptoms that led to admission to the inpatient medical ward or even the intensive care unit. Complications and long-term sequela of COVID-19 are still being reported and studied. The presence of cardiomyopathy, whether established or new-onset and its effect on inpatient mortality, admission to the intensive care unit or length of stay hasn't been studied.  Methods All inpatient hospitalizations in our database between March 1, 2020, and April 30, 2020, due to COVID-19 were reviewed. Patients who had at least a limited echocardiogram during this time were included in the study if they were above the age of 18. Patients were then assigned to three groups. The first group had patients with normal left ventricular systolic function. The second group had established cardiomyopathy that persisted throughout admission. The third group had patients who were found to have new-onset cardiomyopathy during admission.  Results The inpatient mortality, although high and variable, wasn't significantly different between the three groups. Also, there was no significant difference between admission to the intensive care unit, disposition at discharge, or oxygenation status at 24 hours between the three groups. The length of stay in the established cardiomyopathy group was markedly lower, and we suspect that could be due to more aggressive discussions about end-of-life care.  Conclusion Early COVID-19 experience at our center revealed a relatively high mortality rate that was primarily due to respiratory failure. The presence of established or new cardiomyopathy didn't appear to alter the outcomes significantly early in the pandemic.

Renovascular Hypertension with Progressive Atherosclerotic Renal Artery Stenosis in an Elderly Patient with Known Fibromuscular Dysplasia: A Case Report.

BACKGROUND Atherosclerotic renal artery stenosis (ARAS) and renovascular fibromuscular dysplasia (FMD) are 2 of the most common etiologies of renovascular hypertension. They have different pathophysiologies, risk factors, presentations, and treatment options. However, as our population ages, it can become increasingly common to see patients who previously had FMD who develop ARAS at an advanced age, indicated by recurrent renovascular hypertension. CASE REPORT We present a case of a 66-year-old female patient who, in 2007, had presented with uncontrolled hypertension. She underwent magnetic resonance angiography and was found to have bilateral FMD, for which she received balloon angioplasty to a severe lesion on the mid-right renal artery and subsequently had normalization of blood pressures and resolution of symptoms. In 2021 she returned with uncontrolled hypertension while being treated with 3 antihypertensives. Bilateral renal arteriography revealed new severe ostial stenosis of the left renal artery and a patent right renal artery in which balloon angioplasty was performed 14 years ago. Based on the angiographic pattern of this new left RAS, we concluded this lesion was caused by atherosclerosis. The left ostial lesion was treated with a bare-metal stent and the patient was continued on antihypertensive medication and statin; at follow-up 4 months later, her blood pressures had normalized. CONCLUSIONS This case features a patient who developed severe ARAS with underlying history of bilateral renal artery FMD. Clinicians need to be aware that in patients with FMD, worsening renovascular hypertension at an advanced age could indicate the development of new hemodynamically significant ARAS. These patients need repeat diagnostic testing and treatment with medial optimization with or without endovascular revascularization in the appropriate clinical setting.

Assessing Correlation Between Thoracic Impedance and Remotely Monitored Pulmonary Artery Pressure in Chronic Systolic Heart Failure.

Background: Heart failure (HF) readmission continues to be a major health problem. Monitoring pulmonary artery pressure (PAP) and thoracic impedance (TI) are the two modalities utilized for early identification of decompensation in HF patients. We aimed to assess the correlation between these two modalities in patients who simultaneously had both the devices. Methods: Patients with history of New York Heart Association class III systolic HF with a pre-implanted intracardiac defibrillator (ICD) capable of monitoring TI and pre-implanted CardioMEMs™ remote HF monitoring device were included. Hemodynamic data including TI and PAPs were measured at baseline and then weekly. Weekly percentage change was then calculated as: Weekly percentage change = (week 2 - week1)/week 1 × 100. Variability between the methods was expressed by Bland-Altman analysis. Significance was determined as a P-value < 0.05. Results: Nine patients met the inclusion criteria. There was no significant correlation between the assessed weekly percentage changes in pulmonary artery diastolic pressure (PAdP) and TI measurements (r = -0.180, P = 0.065). Using Bland-Altman analytic methods, both methods had no significant difference in agreement (0.011±0.094%, P = 0.215). With the linear regression model applied for Bland-Altman analysis, the two methods appeared to have proportional bias without agreement (unstandardized beta-coefficient of 1.91, t 22.9, P ≤ 0.001). Conclusion: Our study demonstrated that variations exist between measurement of PAdP and TI; however, there is no significant correlation between weekly variations between them.

Carotid Artery Stenting Versus Carotid Artery Endarterectomy in Asymptomatic Severe Carotid Stenosis: An Updated Meta-Analysis.

Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are revascularization options for the management of severe carotid disease in asymptomatic patients. We aimed to compare the peri-procedural outcomes of the two modalities. A systematic review of the databases PUBMED, EBSCO, and Cochrane Library was performed. All the studies that reported periprocedural outcomes (within 30 days) in asymptomatic carotid stenosis patients were included in the meta-analysis. Random effects models with inverse-variance weighting were used to estimate pooled risk ratios (RRs) to compare the outcomes. Fifteen studies (including seven randomized controlled trials) met the inclusion criteria. A total of 15251 patients were included, out of which 6419 (42%) underwent CAS and 8832 (57.9%) underwent CEA. There was no statistical difference in the primary composite outcome of death/stroke/myocardial infarction (MI) (RR 1.02, 95% CI [0.69-1.51], p 0.93). No difference was found in the secondary outcome of all-cause mortality. CAS was associated with a slightly lower risk of MI and cranial nerve palsy. CAS was associated with a slightly higher risk of stroke with no difference in the occurrence of disabling stroke or ipsilateral stroke. In general terms, the study confirms equipoise in the two treatment strategies with a higher risk of MI and cranial nerve palsy with CEA and a higher risk of non-disabling stroke with CAS.

Mobile Atheroma in the Left Internal Carotid Artery: A Case of Impending Doom!

A 69-year-old male presented for evaluation of a carotid bruit. Carotid ultrasound demonstrated the unique finding of a large, highly mobile atheroma in the proximal left internal carotid artery. The presence of a mobile atheroma confers an even higher risk of stroke, so this presentation posed a dilemma in terms of endovascular versus open surgical management strategies. In patients with carotid artery disease, the risk of stroke is related to plaque rupture and distal embolization. The patient underwent successful carotid stenting without periprocedural complications. Our case reports the unusual occurrence of a highly mobile atheroma as the initial presentation of carotid artery disease treated safely with percutaneous carotid artery stenting.

Burnout of Support Personnel in the Cardiac Catheterization Laboratory.

Background: Healthcare professionals experience stressors in the workplace, putting them at elevated risk for burnout. The cardiac catheterization lab is a dynamic environment with high-acuity patients; however, little has been published investigating burnout syndrome among healthcare workers. The aim of the study was to identify the prevalence, demographic, and workload factors, which contribute to burnout syndrome among this population. Methods: This is a multicenter cross-sectional study assessing burnout with the Maslach Burnout Inventory (MBI) among registered nurses and registered cardiac invasive specialists working in the catheterization/electrophysiology lab and cardiac observation unit at four hospital centers in the metro Detroit area. Results: Of the 48 participants, 69% (n = 33) were female. The overall prevalence of burnout syndrome was 33% (n = 16). Significantly more males experienced burnout than females (P < 0.05). Of the participants experiencing burnout, a greater proportion worked in the catheterization lab compared to the cardiac observation unit (93.8% vs. 6.3%). Burned-out participants worked on average more day shifts, ST-segment elevation myocardial infarction (STEMI) call shifts, and extended day shifts per month compared to those not experiencing burnout. The rate of burnout was significantly higher for individuals reporting increased stress during the pandemic (69% vs. 18%, P < 0.05). Conclusions: Registered nurses and registered cardiac invasive specialists working in the cardiac catheterization or electrophysiology lab experience elevated levels of burnout. Greater attention should be placed in identifying and optimizing workplace variables which contribute to burnout among this population.

Coronary Subclavian Steal Syndrome in a 73-Year-Old Woman Presenting with Angiographically Confirmed Subclavian Artery Stenosis Proximal to the Left Internal Mammary.

BACKGROUND Coronary subclavian steal syndrome (CSSS) is an uncommon condition in which a high-grade stenosis of the subclavian artery proximal to an internal mammary artery bypass graft results in retrograde blood flow of the bypass graft. This report is of CSSS in a 73-year-old woman who presented with ventricular tachycardia and angiographically confirmed subclavian artery stenosis proximal to the left internal mammary artery (LIMA) bypass graft 3 years following coronary artery bypass grafting (CABG). CASE REPORT The patient was a 73-year-old woman with a past medical history of multivessel coronary artery disease, found on preoperative evaluation. She underwent 2 vessel CABG in 2018. She was found to have ischemic cardiomyopathy, ejection fraction of 30% to 35% despite revascularization, and an implantable cardiac defibrillator (ICD). Three years following uncomplicated CABG, the patient presented with angina and sustained ventricular tachycardia; ICD therapy was unsuccessful. Ischemia was the etiology of the sustained ventricular tachycardia, and the patient underwent cardiac catheterization, demonstrating high-grade subclavian artery stenosis proximal to the LIMA bypass graft. Intervention of the 80% lesion of the native left anterior descending artery was done with placement of a 2.75×16-mm drug-eluting stent. The patient responded well to treatment, with no subsequent ventricular tachycardia on outpatient follow-up. CONCLUSIONS This report has shown that in patients who present with symptoms of acute coronary syndrome and a history of CABG involving the LIMA, the possibility of CSSS should be considered and investigated by coronary artery imaging so that diagnosis and management are not delayed.

The Relationship Between Coronary Dominance and Positive Results in Myocardial Perfusion Imaging.

Objective Our study aims to evaluate the possible relationship between coronary artery dominance and its effect on accurately identifying reversible ischemia of inferior/inferior-lateral wall on cardiac perfusion imaging. Background Coronary artery dominance is conventionally defined by the vessel which gives the rise to the AV nodal artery/posterior descending artery (PDA). Previous studies have explored the potential effect of coronary dominance on the accuracy of single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) tests in detecting inferior/inferior-lateral wall ischemia; further evidence is necessary to study that potential effect. Methods We conducted a single-center retrospective analysis to explore the potential relationship between coronary artery dominance and inferior/inferior-lateral wall ischemia on SPECT imaging. We identified a cohort of patients with a reversible defect(s) in the inferior and/or inferolateral walls on SPECT MPI who had subsequently undergone invasive coronary angiography. Coronary angiography was used to determine coronary dominance and to confirm the presence/absence of obstructive coronary artery disease in the distribution of the inferior and/or inferolateral wall(s). We correlated the findings on SPECT MPI to coronary angiography to identify true positives and false positive MPIs. Results A cohort of 200 patients was identified, patients in the cohort had undergone stress MPI with reversible defects with subsequent invasive coronary angiography. Baseline characteristics including age, BMI and sex were fairly well-balanced between the groups. The mean age was 68 +/- 11 in the right dominant group and 70 +/- 9 in the non right dominant group. One hundred and sixty-one patients (81%) were found to have right dominant circulation and 39 patients (19%) were found to have left or codominant circulation. Of the 161 patients in the right dominant group, 58 patients (36%) were found to have false positive stress MPI. Of the 39 patients in the left or codominant group, 23 patients (59%) were found to have false positive stress MPI. The incidence of false positive stress MPI in the inferior and inferolateral distribution is significantly higher in patients with non-right dominant coronary anatomy (p-value: 0.01). Conclusion Non-right coronary dominant anatomy could have high false positive MPI results in the inferior and inferolateral distribution. Therefore, the interpreting clinicians should exercise caution during the clinical evaluation of these patients.

Dearth of electrophysiology fellows: perspectives from cardiology fellows-in-training.

BACKGROUND: Over the last 6 years, there has been a high percentage of unfilled cardiac electrophysiology (EP) training spots each year. The authors aimed to investigate potential explanations for the unfilled positions based on a survey from the current Fellows-In-Training (FITs). METHODS: An attempt was made to reach the current cardiology FITs across all programs of the U.S. via email. An anonymous questionnaire was created consisting of 14 questions. Questions posed were regarding factors affecting each participant's interest in or lack of pursuing an EP fellowship. Descriptive statistics of the responses were performed. RESULTS: A total of 26% (35/134) respondents expressed their interest in applying to an EP fellowship. The most common reasons to apply to EP were: Interest in EP, procedural specialty, and work-life balance. Of the 99 respondents that were not applying to EP, the most common reasons not to apply were: Less interest in EP, two-year training duration, and complexity of the specialty. The top reasons for the fellows to believe there is a dearth of EP FITs were: two-year training duration, lack of interest in EP, and the complexity of the specialty. The changes that would encourage EP fellowship interest were: More exposure to EP training during general cardiology fellowship, shortening the EP training duration, and having more information available regarding employment opportunities. CONCLUSION: The study was able to identify factors responsible for vacancies in EP fellowship positions from the view of current cardiology FITs. Stakeholders at the national level involved in framing policies related to fellowship education would be able to utilize this information to address the shortage of EP FITs and increase recruitment to EP fellowships.

Evaluating the Appropriateness of Pulmonary Embolism Admissions in a Community Hospital Emergency Department.

Pulmonary embolism (PE) is a diagnosis on the broader spectrum of venous thromboembolic (VTE) disease. The diagnostic key for clinicians is detecting which patients have a "high risk" of complications or mortality and who are in the "low-risk" population. The Pulmonary Embolism Severity Index (PESI) and HESTIA scores are validated risk stratification tools to determine if patients diagnosed with PE can be successfully managed in the outpatient versus inpatient setting. We aimed to investigate the appropriateness of PE admissions to our institution based on the risk stratification recommendations from PESI and HESTIA scores. We retrospectively identified 175 patients admitted with a diagnosis of PE over one year at our hospital. Baseline demographics, length of admission, and admitting diagnoses were collected for all patients included in this study. PESI and HESTIA scores were then calculated for all included patients. The average PESI score was 91.65 (95% confidence interval: 86.33, 96.97). There were 87 patients (49.7%) that had a low or very low PESI score of fewer than 85 points. Fifty-seven patients (33.7%) presented with a HESTIA score of 0. The risk stratification score indicates these patients as low risk, and appropriate for outpatient management. However, they were instead admitted to the hospital which contributes to increased costs, risk of adverse events, etc. There were 0 mortalities reported for patients in the "low or very low risk" groups, with four reported mortalities in the "very high risk" groups.  In our cohort, 33.7%-49.7% of admissions for PE were risk-stratified as "low risk" and qualified for outpatient management based on HESTIA and PESI risk stratification scores, respectively. The underutilization of validated risk scores upon initial diagnosis of PE may lead to worse outcomes and increased healthcare expenditure.

Assessing the Impact of Intensified Hypertension (HTN) Treatment Guidelines: A Single Center Experience.

INTRODUCTION:  Hypertension (HTN) is an independent risk factor for heart disease, stroke, and premature death. In 2017 there was a shift in the definition of HTN by the American College of Cardiology (ACC), as well as the American Heart Association (ACC/AHA), resulting in lower blood pressure (BP) readings meeting criteria for diagnosis. Our study aimed to explore the impact the change had on a single cardiology practice's management of patients with HTN. METHODS: We performed a retrospective chart review of a single cardiology practice. We separated the time into two categories: 12 months before and 12 months after the reclassification of HTN categories in November 2017. A paired t-test analysis was done comparing averaged blood pressures (BPs) in each of the two time periods, as well as the number of medications in each time period and several subgroup analyses. RESULTS: A total of 441 patients were included in the final analysis. Patients were prescribed an average of 2.61 ± 1.20 medications at baseline, and 2.74 ± 1.22 medications post-reclassification (p < 0.0001). There was an average of 0.82 ± 1.28 medication changes per patient. The overall average BP was 133.7 ± 14.1/76.4 ± 9.5 at baseline, and 131.3 ± 13.1/76.7 ± 7.7 after the recategorization [Δ -2.41 (95% CI 1.18-3.63)/0.269 (95% CI -0.29 to 0.459); p<0.0001 for systolic blood pressure (SBP), p=0.467 for diastolic blood pressure (DBP)]. CONCLUSION: The change in definition of HTN significantly impacted this single cardiology practice. There was a statistically significant increase in antihypertensive medications prescribed with an expected decrease in BP observed in this study.

Isolated Sub-Pulmonic Valve Endocarditis in a Patient With a History of Konno Procedure and Mechanical Aortic Valve.

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Successful Medical Management of an Acute Ascending Aortic Dissection After Coronary Artery Bypass Graft Surgery.

Aortic dissection is an acute and life-threatening disease entity. Mortality rates increase every hour after the presentation. Typical treatment includes medical management of blood pressure and heart rate control followed by prompt transfer to an operating room for surgical repair. We present a case of medically managed Stanford type A aortic dissection in a postoperative coronary artery bypass graft (CABG) patient. A 77-year-old man with a past medical history of hypertension and hyperlipidemia presented after an outpatient nuclear stress test demonstrated a reversible inferior wall defect. He was subsequently referred to a cardio-thoracic surgeon and underwent coronary artery bypass graft (CABG) surgery. Three weeks later, the patient presented to the emergency department complaining of a productive cough, nausea, vomiting, and fever. He was diagnosed with sepsis secondary to pneumonia. A CT chest demonstrated a new 3.9 cm long segment of dissection in the ascending thoracic aorta. Due to postoperative recovery from recent CABG, a decision was made to treat the ascending thoracic aortic dissection (Stanford type A) medically. He was advised to continue intensive antihypertensive medications and close follow-up with a cardiologist and cardiothoracic surgeon on an outpatient basis. Subsequent follow-up CT chest angiography at one month, four months, and 12 months later did not demonstrate the progression of the ascending aortic dissection. Decisions to deviate from the usual care should best be taken in a multidisciplinary team approach. Patients should clearly be informed about the rationale behind these complex decisions.

Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial.

BACKGROUND: Previous studies have suggested that haemodynamic-guided management using an implantable pulmonary artery pressure monitor reduces heart failure hospitalisations in patients with moderately symptomatic (New York Heart Association [NYHA] functional class III) chronic heart failure and a hospitalisation in the past year, irrespective of ejection fraction. It is unclear if these benefits extend to patients with mild (NYHA functional class II) or severe (NYHA functional class IV) symptoms of heart failure or to patients with elevated natriuretic peptides without a recent heart failure hospitalisation. This trial was designed to evaluate whether haemodynamic-guided management using remote pulmonary artery pressure monitoring could reduce heart failure events and mortality in patients with heart failure across the spectrum of symptom severity (NYHA funational class II-IV), including those with elevated natriuretic peptides but without a recent heart failure hospitalisation. METHODS: The randomised arm of the haemodynamic-GUIDEed management of Heart Failure (GUIDE-HF) trial was a multicentre, single-blind study at 118 centres in the USA and Canada. Following successful implantation of a pulmonary artery pressure monitor, patients with all ejection fractions, NYHA functional class II-IV chronic heart failure, and either a recent heart failure hospitalisation or elevated natriuretic peptides (based on a-priori thresholds) were randomly assigned (1:1) to either haemodynamic-guided heart failure management based on pulmonary artery pressure or a usual care control group. Patients were masked to their study group assignment. Investigators were aware of treatment assignment but did not have access to pulmonary artery pressure data for control patients. The primary endpoint was a composite of all-cause mortality and total heart failure events (heart failure hospitalisations and urgent heart failure hospital visits) at 12 months assessed in all randomly assigned patients. Safety was assessed in all patients. A pre-COVID-19 impact analysis for the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT03387813. FINDINGS: Between March 15, 2018, and Dec 20, 2019, 1022 patients were enrolled, with 1000 patients implanted successfully, and follow-up was completed on Jan 8, 2021. There were 253 primary endpoint events (0·563 per patient-year) among 497 patients in the haemodynamic-guided management group (treatment group) and 289 (0·640 per patient-year) in 503 patients in the control group (hazard ratio [HR] 0·88, 95% CI 0·74-1·05; p=0·16). A prespecified COVID-19 sensitivity analysis using a time-dependent variable to compare events before COVID-19 and during the pandemic suggested a treatment interaction (pinteraction=0·11) due to a change in the primary endpoint event rate during the pandemic phase of the trial, warranting a pre-COVID-19 impact analysis. In the pre-COVID-19 impact analysis, there were 177 primary events (0·553 per patient-year) in the intervention group and 224 events (0·682 per patient-year) in the control group (HR 0·81, 95% CI 0·66-1·00; p=0·049). This difference in primary events almost disappeared during COVID-19, with a 21% decrease in the control group (0·536 per patient-year) relative to pre-COVID-19, virtually no change in the treatment group (0·597 per patient-year), and no difference between groups (HR 1·11, 95% CI 0·80-1·55; p=0·53). The cumulative incidence of heart failure events was not reduced by haemodynamic-guided management (0·85, 0·70-1·03; p=0·096) in the overall study analysis but was significantly decreased in the pre-COVID-19 impact analysis (0·76, 0·61-0·95; p=0·014). 1014 (99%) of 1022 patients had freedom from device or system-related complications. INTERPRETATION: Haemodynamic-guided management of heart failure did not result in a lower composite endpoint rate of mortality and total heart failure events compared with the control group in the overall study analysis. However, a pre-COVID-19 impact analysis indicated a possible benefit of haemodynamic-guided management on the primary outcome in the pre-COVID-19 period, primarily driven by a lower heart failure hospitalisation rate compared with the control group. FUNDING: Abbott.

Coronary Embolism despite CHA2DS2-VASc Score of Zero: Should We Reconsider Anticoagulation?

Coronary embolism (CE) is a rare but important cause of acute coronary syndrome. The most common source of emboli is considered to be infective endocarditis and atrial fibrillation. Various studies have estimated the prevalence of coronary embolism; however, diagnosis is challenging. Often, it is difficult to differentiate. Nonetheless, this is an important step as treating the underlying cause of an embolism is essential to limit recurrence. However, while this condition may have fatal consequences, due to its uncommon occurrence, there is no consensus on diagnosis and management. We present a case of a 53-year-old obese male, with a history of paroxysmal atrial fibrillation not on anticoagulation due to a low CHA2DS2-VASc score, who presented with chest pain associated with lightheadedness. ECG on admission revealed coarse atrial fibrillation, and troponin was gradually elevating on serial lab workup. Coronary angiography revealed a distal left anterior descending artery occlusion with apical wall akinesis without any evidence of atherosclerotic coronary artery disease. A presumptive diagnosis of coronary embolism secondary to paroxysmal atrial fibrillation was made, and the patient was started on anticoagulation despite a low CHA2DS2-VASc score. This case not only highlights coronary embolism but also illustrates that a low CHA2DS2-VASc score does not mean there is no risk of emboli. For such patients, it is important to take clinical reasoning into account along with the CHA2DS2-VASc score to determine the benefit of anticoagulation.

A Rare Anatomical Variant: Congenital Absence of the Right Coronary Artery with Left Circumflex Artery Supplying the Right Coronary Artery (RCA) Territory.

BACKGROUND While most coronary congenital anomalies are uncommon, comprising less than 2% of the general population, a single coronary artery is an especially rare finding within this broader category. It involves a lone vessel forming a single ostium from the aortic trunk. This vessel is then the source through which cardiac blood supply originates. Such congenital coronary artery anomalies are rare but can have clinically relevant consequences such as sudden death and other cardiac complications. Nonetheless, they are usually incidental findings and can be asymptomatic. This report discusses the case of a female patient found to have an absence of the right coronary artery, with the left circumflex supplying the right coronary artery territory. CASE REPORT We report a rare case of a 66-year-old woman who presented with substernal chest pain and shortness of breath. Vital signs, laboratory work-up, and resting electrocardiogram did not reveal an underlying etiology. However, an exercise stress test was positive. Left heart catheterization was performed and revealed a dominant left circumflex artery supplying the entire right coronary territory. Further imaging revealed the absence of a separate right coronary artery ostium. The patient was treated with a beta-blocker, high-intensity statin, and a nitrate. CONCLUSIONS Single left coronary artery, especially with the absence of the right coronary artery, is particularly rare, but can have significant clinical implications. Prompt diagnosis is important but challenging considering the variable presentation of this condition. It is important to review diagnostic modalities available and the treatment for patients.

Isolated Ventricular Septal Aneurysm: A Differential Diagnosis for a Right Sinus of Valsalva Aneurysm.

BACKGROUND A ventricular septal aneurysm (VSA) is rare and almost always an incidental finding on cardiac imaging. It is rarely an isolated phenomenon and is more commonly associated with other forms of congenital heart disease such a ventricular septal defect (VSD). Differentiating a ventricular septal aneurysm from an aneurysm of the right sinus of Valsalva is crucial as the latter usually has a more aggressive course and may require surgical intervention. Cardiac computed tomography (cardiac CT) or cardiac magnetic resonance imaging (CMR) may help confirm the diagnosis. CASE REPORT We report a case of a 42-year-old obese Japanese man with a past medical history of hyperlipidemia who described occasional effort-related palpitations when climbing stairs over the past few months but no anginal symptoms. Echocardiogram revealed normal left ventricular systolic with a presumed right sinus of Valsalva aneurysm measuring around 1.5 cm. A coronary CTA was obtained to further delineate the aneurysm and revealed normal CT angiographic appearance of a right dominant coronary artery circulation with a small aneurysmal outpouching of the membranous ventricular septum measuring 13×17 mm without any evidence of shunting, along with focal calcification of the medial aspect of the tricuspid annulus. The right sinus of Valsalva appeared normal on coronary CTA. CONCLUSIONS Membranous ventricular septal aneurysm is a rare condition that is almost always an incidental finding on echocardiography and can be mistaken for an aneurysm of the right sinus of Valsalva. Multimodality imaging and high degree of clinical suspicion are needed to accurately diagnose a ventricular septal aneurysm and to achieve favorable outcomes. A VSA usually has a benign course and is rarely a cause of arrythmia, right ventricular outflow obstruction, or valvular insufficiency.