Right heart catheterization in clinical practice: a review of basic physiology and important issues relevant to interpretation.

Pulmonary artery catheterization is a diagnostic procedure in which a catheter is inserted through a central vein and advanced toward the pulmonary artery to measure right atrial, right ventricular, and pulmonary artery pressures, estimate cardiac output, identify intracardiac shunts, and measure pulmonary vascular resistance. Hemodynamic measurements can provide a better understanding of the pathophysiology of heart failure and pulmonary hypertension, but their proper assessment and optimal use can be challenging due to differences in techniques that can lead to differences in conclusions and therapeutic management strategies. In this review, we will discuss right heart catheterization and its role in clinical practice (e.g., shunt evaluation, management of cardiogenic shock) and summarize important concerns related to measurement and interpretation.

Association between right heart catheterization hemodynamics and glycosylated hemoglobin levels in adults with heart failure with reduced ejection fraction.

This study hypothesized that elevated glycosylated hemoglobin (HbA1c) levels are associated with abnormal right heart catheterization (RHC) hemodynamic parameters in patients with heart failure with reduced ejection fraction (HFrEF) and no prior diagnosis of diabetes. Methods: Retrospective cohort study of adult patients with HFrEF and no prior diagnosis of diabetes who underwent RHC and had HbA1c levels measured 30 days before or after the RHC. This study excluded patients who had received blood transfusions within 90 days prior to HbA1c measurement and patients with known diabetes. Univariate and multivariate regression analyses adjusted for age, sex, and BMI were used to test for an association between RHC hemodynamic parameters and HbA1c levels. Results: A total of 136 patients were included with a mean age of 55 ± 15 years and mean HbA1c was 5.99 ± 0.64%. Unadjusted univariate models showed that HbA1c is significantly associated with cardiac index (CI) by the Fick method and thermodilution, right atrial pressure (RAP), and mean pulmonary arterial pressure (MPAP). After multivariate analysis, for every one unit increase in HbA1c, there was a 0.19 and 0.26 L/min/m2 decrease in expected CI by thermodilution and by the Fick method (P = 0.03 and P < 0.01), respectively. For every one unit increase in HbA1c, there was a 2.39 mmHg increase in expected RAP (P = 0.01). Conclusion: Elevated HbA1c levels measured within 30 days before or after the index RHC in patients with a left ventricular ejection fraction <40% were associated with congestive hemodynamic parameters.

Cardiac amyloidosis-An underdiagnosed cause of heart failure: A case report and review of literature.

Restrictive cardiomyopathy secondary to cardiac amyloidosis is an underdiagnosed, but treatable, cause of heart failure involving an extracellular deposition of misfolded protein. Hereby, we report a case of a female patient with history of nephrotic syndrome for 1 year who subsequently presented with symptoms of heart failure. The findings on cardiac imaging supported the suspicion of cardiac amyloidosis. Further laboratory workup for amyloidosis was pursued along with endomyocardial biopsy which confirmed amyloidosis-AL type. Patient was started on chemotherapy. The case underscores the importance of a timely diagnosis with the help of symptomatology and imaging along with a multidisciplinary approach for patient care.

Heart Failure as the Initial Clinical Manifestation of Becker Muscular Dystrophy in an Adult.

Congestive heart failure is an uncommon initial presentation for dystrophin-deficient muscular dystrophies. Cardiac manifestations may appear in late disease stages, although they classically present after musculoskeletal symptoms develop. This case report describes a patient who presented with heart failure and was newly diagnosed with Becker muscular dystrophy. The objective is to recognize Becker muscular dystrophy as a potential cause of dilated cardiomyopathy in young patients, even in the absence of clinically overt musculoskeletal symptoms.

Hypertrophic Cardiomyopathy in the Elderly: A Case Identified With Genetic Screening.

Hypertrophic cardiomyopathy (HCM) is a hereditary disease with an autosomal dominant pattern of inheritance, that is caused by a mutation in one of several sarcomere genes that encodes components of the contractile system of the heart. Hypertrophic cardiomyopathy has been described as a disease that is more heavily diagnosed in the second decade of life, that may present with abnormal syncopal episodes or sudden cardiac death. However, with a better understanding of the genetic changes that occur in HCM and with improved imaging techniques, there has now been an increased recognition of a late-onset disease that can occur in the elderly population. We report a case of a 73-year-old woman who was found to have HCM after various clinical events took place.

Cardiac Adverse Events after Vaccination-A Systematic Review.

The Vaccine Adverse Event Reporting System database has been used to report adverse events following several vaccines. We studied the patient population predisposed to such reactions and how these reactions differ with respect to the vaccine type. We searched the electronic databases PubMed, EMBASE, and Scopus up to 9 July 2021 for any study describing cardiac adverse events attributed to the vaccination. A total of 56 studies met the criteria comprising 340 patients. There were 20 studies describing cardiac adverse events following smallpox vaccination, 11 studies describing adverse events after influenza vaccination, and 18 studies describing adverse events after COVID-19 vaccination. There was a total of six studies describing cardiac adverse events after the pneumococcal vaccine, tetanus toxoid, cholera vaccine, and rabies vaccine. Adverse events following influenza vaccination occurred more commonly in older females within an average duration of four days from vaccination. Pericardial involvement was the most reported adverse event. Adverse events following COVID-19 vaccination happened at a mean age of 42.7 years, more commonly in males, and mostly after a second dose. Adverse events following smallpox vaccination occurred more commonly in younger males, with an average onset of symptoms from vaccination around 16.6 days. Adverse events were mostly myopericarditis; however, the acute coronary syndrome has been reported with some vaccines.

Dilated cardiomyopathy as the initial presentation of Becker muscular dystrophy: a systematic review of published cases.

There are scarce publications regarding the presentation and outcome of Becker muscular dystrophy in adulthood when idiopathic dilated cardiomyopathy is the initial disease manifestation. We performed a systematic review using Medline, Embase, Cochrane, and Scopus to identify cases of adults with idiopathic dilated cardiomyopathy who were subsequently diagnosed with Becker muscular dystrophy from inception through August 2020. Six cases were found. We identified young males (Median age: 26 years) with Becker muscular dystrophy who first presented with dilated cardiomyopathy. Most patients initially presented with congestive heart failure symptoms (5/6, 83%), and had a median left ventricular ejection fraction of 23%. One case did have calf pseudohypertrophy. Musculoskeletal symptoms later appeared one to six years after the initial dilated cardiomyopathy presentation. Heart transplantation was the most common management strategy (4/6, 67%). A left ventricular assist device was used in one case as a bridge to heart transplant. Dilated cardiomyopathy can be the initial presentation of Becker muscular dystrophy in the third to fourth decades of life in adult patients, and musculoskeletal symptoms can be subclinical.

Efficacy of Mechanical Circulatory Support Used Before Versus After Primary Percutaneous Coronary Intervention in Patients with Cardiogenic Shock From ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis.

BACKGROUND: Optimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS. METHODS: We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models. RESULTS: Ten studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77-1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26-0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14-0.62, I2 = 0%, p = 0.001, respectively). CONCLUSIONS: In patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association.

Vaccine-preventable disease hospitalized patients with heart failure with reduced ejection fraction.

BACKGROUND: Over five million Americans suffer from heart failure (HF), and this is associated with multiple chronic comorbidities and recurrent decompensation. Currently, there is an increased incidence in vaccine-preventable diseases (VPDs). We aim to investigate the impact of HF with reduced ejection fraction (HFrEF) in patients hospitalized with VPDs. HYPOTHESIS: Patient with HFrEF are at higher risk for VPDs and they carry a higher risk for in-hospital complications. METHODS: Retrospective analysis from all hospital admissions from the 2016-2018 National Inpatient Sample (NIS) using the ICD-10CM codes for patients admitted with a primary diagnosis of VPDs with HFrEF and those without reduced ejection fraction. Outcomes evaluated were in-hospital mortality, length of stay (LOS), healthcare utilization, frequency of admissions, and in-hospital complications. Multivariate regression analysis was conducted to adjust for confounders. RESULTS: Out of 317 670 VPDs discharges, we identified 12 130 (3.8%) patients with HFrEF as a comorbidity. The most common admission diagnosis for VPDs was influenza virus (IV) infection (75.0% vs. 64.1%; p < .01), followed by pneumococcal pneumonia (PNA) (13% vs. 9.4%; p < .01). After adjusting for confounders, patients with HFrEF had higher odds of having diagnosis of IV (adjusted [aOR], 1.42; p < .01) and PNA (aOR, 1.27; p < .01). Patients with VPDs and HFrEF had significantly higher odds of mortality (aOR, 1.76; p < .01), LOS, respiratory failure requiring mechanical ventilation, and mechanical ventilation for less than 96 h. CONCLUSION: Influenza and PNA were the most common VPDs admitted to the hospital in patients with a concomitant diagnosis of HFrEF. They were associated with increased mortality and in-hospital complications.

Acute Myocardial Infarction Associated With a Mobile Left Ventricular Thrombi.

The majority of acute coronary syndromes are caused by coronary artery thrombotic occlusions secondary to atherosclerotic plaque erosion or rupture. Coronary embolism is an important yet forgotten underlying cause of acute coronary syndrome. We present a case of a young patient who presented with ST elevation myocardial infarction suspected to be secondary to coronary embolization originating from a left ventricular thrombus.

A Case of Early Hereditary Transthyretin Amyloid Cardiomyopathy Recognition With Genetic Screening: A Case Report.

Background: Transthyretin amyloid cardiomyopathy (ATTR-CM) is one of the most common types of cardiac amyloidosis. Amyloid cardiomyopathy more commonly affects men, elderly, and 3% to 4% of the African-American population. ATTR-CM suspicion and diagnosis is challenging; however, awareness of the disease is increasing, and best practices to identify it are being proposed. The approach to suspected cases of ATTR-CM relies on the presence of heart failure, red flag signs and symptoms, and age >65 or >70 for men and women respectively. Little is known about cases when it presents in early ages. Case: We report a 62-year-old African American male with past medical history of hyperlipidemia, prostate cancer, hypertension, bilateral carpal tunnel surgery that had debuted with a cardiac arrhythmia at age 55 and was diagnosed with heart failure several years later. Restrictive cardiomyopathy was suspected, and genetic screening was sent for ATTRm which confirmed a pathogenic trasnthyretin gene mutation. Endomyocardial biopsy was performed which confirmed cardiac amyloid deposition. Discussion: ATTR-CM is a rare disease with an increasing prevalence. Cases with out of proportion signs and symptoms of heart failure with preserved ejection fractions should raise the suspicion of ATTR-CM despite age.

Acute coronary artery dissection after multiple bee stings.

The occurrence of an acute coronary syndrome following an anaphylactic or anaphylactoid reaction is known as Kounis syndrome. Previous reports of Kounis syndrome described an acute coronary syndrome due either to vasospasm or atherosclerotic rupture of a coronary artery in the presence of cutaneous manifestation from the anaphylactic reaction. We report a case of a 33-year-old man who presented with anterior wall acute myocardial infarction immediately after honeybee stings without the presence of cutaneous manifestations other than the bee sting lesions. Emergent coronary arteriography revealed dissection of the proximal left anterior descending artery, which was treated with balloon dilation with an excellent outcome.

Loeffler Endocarditis and Associated Parasitosis: A Diagnostic Challenge.

Loeffler endocarditis is relatively under-recognized and can impose a diagnostic challenge. We present a case of Loeffler endocarditis where eosinophilia was associated with parasitosis. This case highlights the importance of clinical clues in a patient with restrictive cardiomyopathy, and appropriate ancillary testing which helps guide further management.

Left ventricular myxoma: A contractile mass causing intracavitary obstruction and severe pulmonary hypertension.

Cardiac myxomas can be fatal and left ventricular (LV) myxomas with papillary muscle and mitral valve (MV) involvement are rare. The following case is that of a 55-year-old woman who developed signs and symptoms of pulmonary hypertension. Imaging revealed a contractile mass in the LV that was in continuum with the papillary muscles and affected MV function. Her clinical course, radiologic, and hemodynamic findings are discussed. Finally, her surgical extraction technique is described in addition to potential complications encountered.