Carmustine-Induced Takotsubo Cardiomyopathy.

Carmustine is an intravenous alkylating agent that inhibits DNA synthesis and protein synthesis by forming cross-links in DNA and RNA and ultimately causing cell death. We report a rare case of Takotsubo cardiomyopathy that is thought to be related to carmustine, where the patient presented with chest pain, and ST depression within 12 hours of carmustine therapy. Workup, including echocardiography, showed global hypokinesis of the left ventricle with regional variations; mid and apical anterior septum and apex were akinetic with left ventricular ejection fraction (EF) of 30%. Cardiac catheterization showed nonobstructive coronary artery disease. The patient was treated with a beta-blocker, angiotensin receptor-neprilysin inhibitor (ARNi), and aldosterone receptor antagonists. Two days later, he had a repeat echocardiogram that showed improved EF. After stem cell infusion, his course was complicated with atrial fibrillation with rapid ventricular response and septic shock. Unfortunately, he suffered a cardiac arrest and expired. Carmustine-related cardiomyopathy seems to be very rare, and, to our knowledge, this is the first case report.

COVID-19 Vaccination-Induced Cardiomyopathy Requiring Permanent Left Ventricular Assist Device.

Myocarditis was identified as a rare but serious adverse event that can occur after mRNA-based coronavirus disease 2019 (COVID-19) vaccination, particularly in young males. During the COVID-19 pandemic, we report a case of a young obese male without multiple comorbidities who presented with abdominal pain and was found to have severe myocarditis/cardiomyopathy, which was likely due to mRNA-based COVID-19 vaccination. The patient had left ventricular assist device (LVAD) implantation during hospitalization. Myocarditis/cardiomyopathy may be a rare complication of the mRNA-based COVID vaccine; however, one should maintain a high index of suspicion that these vaccines may cause irreversible cardiomyopathy if the patient had prior COVID-19 infection.

Clinical In-Hospital Outcomes of Acute Myocardial Infarction in Patients With Hematological Malignancies.

Introduction The purpose of our study is to determine in-hospital outcomes of acute myocardial infarction in patients with hematological malignancies and their subtypes. Method Patient data were obtained from the nationwide inpatient sample (NIS) database between the years 2009-2014. Patients with hematological cancer subtypes and acute MI (non-ST segment elevation myocardial infarction and ST-segment elevation myocardial infarction (NSTEMI/STEMI) were identified using validated international classification of diseases (ninth revision) and clinical modification (ICD-9-CM) codes. Statistical analysis using the chi-square test was performed to determine the hospital outcomes of acute MI in patients with hematological cancers and subtypes. Results The prevalence of acute myocardial infarction was 2.4% in patients with hematological neoplasms (N=3,027,800). Amongst the subtypes of blood cancers, the highest prevalence of acute MI was seen in lymphocytic leukemia (2.9%). The mortality of MI in patients with hematological malignancies was 16.8% vs 8.8% in patients with non-hematological malignancies, in-hospital costs were $25469 ± 36763 vs. $20534 ± 24767, and length of in-hospital stay was 8.3 ± 10 vs 6.3 ± 7.8 days. Amongst the hematological cancer subtypes, the highest mortality of acute MI was found in myeloid leukemia (23%) followed by multiple myeloma (MM) (17.9%), lymphocytic leukemia (15.9%), and lymphoma (14.4%). The length of stay and hospitalization cost was highest for myeloid leukemia, followed by MM, lymphocytic leukemia, and lymphoma. Conclusion This study showed that acute MI in patients with hematological malignancies has higher in-hospital mortality, length of stay, and cost. Amongst the blood neoplasm subtypes the highest mortality, length of hospital stay, and hospitalization cost were found in myeloid leukemia.

Predictors of Early and Late Atrioventricular Block Requiring Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Single-Center Experience.

PURPOSE: Complete heart block requiring permanent pacemaker can occur early following transcatheter aortic valve replacement (TAVR) due to mechanical compression of the aortic valve annulus and associated atrio-ventricular (AV) conduction system. Data are limited regarding late PM implantation after TAVR. The purpose of this study was to determine predictors of early vs. late PM implantation post-TAVR procedure. METHODS: Baseline characteristics of patients who required PM <7 days following TAVR were compared with patients who required a PM >7 days to 1 year following TAVR using Chi-Square and multivariate regression analysis. RESULTS: There were 362 TAVR patients, of which 39 (10.4%) received a PM after TAVR. Of these 18 (4.6%) patients required PM within 7 days after TAVR, and 21 (5.8%) required PM after 7 days and up to 1 year later. Right bundle branch block (RBBB) (OR 6.721, CI 2.3-36.9, p < 0.005) was a positive predictor of early PM placement. Left bundle branch block (LBBB) (OR = 3.5, CI 1.19-10.80, p-value < 0.05) and atrial fibrillation (AF) (OR = 3.5, 1.36-9.4 p < 0.05) were predictors for late PM. Early and late PM were associated with a longer median hospital stay compared to no PM (4.9 ± 4.86 days vs. 10.1 ± 10.04 days vs. 6.10 ± 6.02 days). The incidence of heart failure was higher in the late PM group. The overall motility was not increased in early and late PM compared to no PM. CONCLUSION: Patients requiring PM implant after TAVR was 10.4%, of which 5.8% need PM >7 days post-TAVR. RBBB is a predictor for early PM. AF and LBBB were predictors for late PM.

Cardiac pseudoaneurysm as a complication of native mitral valve infective endocarditis.

BACKGROUND: The delayed development of a mitral valve annulus pseudoaneurysm is a rare and late complication of a native mitral abscess cavity. CASE SUMMARY: Currently, there are no documented cases of a pseudoaneurysm developing from an abscess cavity of the posterior annulus of the native mitral valve. We report a case of a patient who presented with worsening progressive shortness of breath that was found to be secondary to a pseudoaneurysm. This was detected by 2D echocardiogram and cardiac computed tomography angiography. DISCUSSION: In our case, the patient developed a late complication of a ventricular pseudoaneurysm originating from the mitral annular area of the abscess cavity. Per the surgical literature, one method to avoid the aforementioned complication is via cavity repair with a bovine patch.

Association of atrial fibrillation and various cancer subtypes.

BACKGROUND: Studies have shown that the incidence of atrial fibrillation (AF) in cancer is most likely due to the presence of inflammatory markers. The purpose of our study is to determine the association of AF with different cancer subtypes and its impact on in-hospital outcomes. METHODS: Data were obtained from the National Inpatient Sample database between 2005 and 2015. Patients with various cancers and AF were studied. ICD-9-CM codes were utilized to verify variables. Patients were divided into three age groups: Group 1 (age < 65 years), Group 2 (age 65-80 years), and Group 3 (age > 80 years). Statistical analysis was performed using Pearson chi-square and binary logistic regression analysis to determine the association of individual cancers with AF. RESULTS: The prevalence of AF was 14.6% among total study patients (n = 46 030 380). After adjusting for confounding variables through multivariate regression analysis, AF showed significant association in Group 1 with lung cancer (odds ratio, OR = 1.92), multiple myeloma (OR = 1.59), non-Hodgkin lymphoma (OR = 1.55), respiratory cancer (OR = 1.55), prostate cancer (OR = 1.20), leukemia (OR = 1.12), and Hodgkin's lymphoma (OR = 1.03). In Group 2, the association of AF with multiple myeloma (1.21), lung cancer (OR = 1.15), Hodgkin lymphoma (OR = 1.15), non-Hodgkin lymphoma (OR = 1.12), respiratory cancer (OR = 1.08), prostate cancer (OR = 1.06), leukemia (OR = 1.14), and colon cancer (OR = 1.01) were significant. In Group 3, AF showed significant association with non-Hodgkin lymphoma (OR = 1.06), prostate (OR = 1.03), leukemia (OR = 1.03), Hodgkin's lymphoma (OR = 1.02), multiple myeloma (OR = 1.01), colon cancer (OR = 1.01), and breast cancer (OR = 1.01). The highest mortality was found in lung cancer in age <80 and prostate cancer in age >80. CONCLUSION: In patients age <80 years, AF has significant association with lung cancer and multiple myeloma, whereas in patients age >80 years, it has significant association with non-Hodgkin lymphoma and prostate cancer. In patients age <80 years, increased mortality was seen in AF with lung cancer and in patients age >80 years, increased mortality was seen in those with AF and prostate cancer. TWITTER ABSTRACT: In age <80, lung cancer and multiple myeloma have a strong association with AF while thyroid and pancreatic cancers have no association with AF at any age. In age greater than 80, NHL and prostate cancer have a significant association with AF.

Association between atrial fibrillation and bundle branch block.

BACKGROUND: The association between atrial fibrillation (Afib) and sinus and AV nodal dysfunction has previously been reported. However, no data are available regarding the association between Afib and bundle branch block (BBB). METHODS: Patient data were obtained from the Nationwide Inpatient Sample (NIS) database between years 2009 and 2015. Patients with a diagnosis of Afib and BBB were identified using validated International Classification of Diseases, 9th revision, and Clinical Modification (ICD-9-CM) codes. Statistical analysis using the chi-square test and multivariate linear regression analysis were performed to determine the association between Afib and BBB. RESULTS: The total number of patients with BBB was 3,116,204 (1.5%). Patients with BBB had a mean age of 73.5 ± 13.5 years, 53.6% were males, 39.1% belonged to the age group ≥80 years, and 72.9% were Caucasians. The prevalence of Afib was higher in the BBB group, as compared to the non-BBB group (29% vs 11.8%, p value<.001). This association remained significant in multivariate regression analysis with an odds ratio of 1.25 (CI: 1.24-1.25, P < .001). Among the subtypes of BBB, Afib was comparatively more associated with RBBB (1.32, CI 1.31-1.33, p value<.0001) than LBBB (1.17, CI 1.16-1.18, p value<.0001). The mean cost was higher among Afib with BBB, compared with Afib patients without BBB ($15 795 vs $14 391, p value<.0001). There was no significant difference in the mean length of stay (5.6 vs 5.9 days, p value<.0001) or inpatient mortality (4.9% vs 4.8%). CONCLUSION: This study demonstrates that prevalence of Afib is higher in patients with BBB than without BBB. Cost are higher for Afib patients with BBB, compared to those without BBB, with no significant increase in mortality or length of stay.

Clinical outcomes of atrial fibrillation with hyperthyroidism.

BACKGROUND: Atrial fibrillation (Afib) is a common cardiac manifestation of hyperthyroidism. The data regarding outcomes of Afib with and without hyperthyroidism are lacking. HYPOTHESIS: We hypothesized that patients with Afib and hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism. METHODS: We queried the National Inpatient Sample database for years 2015-2017 using Validated ICD-10-CM codes for Afib and hyperthyroidism. Patients were separated into two groups, Afib with hyperthyroidism and without hyperthyroidism. RESULTS: The study was conducted with 68 095 278 patients. A total of 9 727 295 Afib patients were identified, 90 635 (0.9%) had hyperthyroidism. The prevalence of hyperthyroidism was higher in patients with Afib (0.9% vs 0.4%, P < .001), compared with patients without Afib. Using multivariate regression analysis adjusting for various confounding factors, the odds ratio of Afib with hyperthyroidism was 2.08 (CI 2.07-2.10; P < .0001). Afib patients with hyperthyroidism were younger (71 vs 75 years, P < .0001) and more likely to be female (64% vs 47%; P < .0001) as compared with Afib patients without hyperthyroidism. Afib patients with hyperthyroidism had lower prevalence of CAD (36% vs 44%, P < .0001), cardiomyopathy (24.1% vs 25.9%, P < .0001), valvular disease (6.9% vs 7.4%, P < .0001), hypertension (60.7% vs 64.4%, P < .0001), diabetes mellitus (29% vs 32%, P < .0001) and obstructive sleep apnea (10.5% vs 12.2%, P < .0001). Afib with hyperthyroidism had lower hospitalization cost ($14 968 ± 21 871 vs $15 955 ± 22 233, P < .0001), shorter mean length of stay (5.7 ± 6.6 vs 5.9 ± 6.6 days, P < .0001) and lower in-hospital mortality (3.3% vs 4.8%, P < .0001. The disposition to home was higher in Afib with hyperthyroidism patients (51% vs 42; P < .0001). CONCLUSION: Hyperthyroidism is associated with Afib in both univariate and multivariate analysis. Afib patients with hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism.

Shock Secondary to Aortic Root Abscess With Sterile Blood Culture.

Shock caused by an aortic root abscess is a rare phenomenon. Due to its rarity, it is commonly not diagnosed on time to have a favorable prognosis for the patient. Our case involves an 80-year-old male presenting with leukocytosis, lactic acidosis, and hypoglycemia. Initial studies were not fruitful in determining the cause of septic shock. However, an echocardiogram conducted to clarify the finding of a non-ST segment myocardial infraction led to the incidental finding of an aortic root abscess with retrograde flow, suggesting a perforated abscess without endocarditis. Though the patient expired on day seven, our case demonstrates the importance of echocardiography in diagnosing an aortic root abscess in cases with a sterile blood culture and uneventful initial lab investigations.

Burden of atrial fibrillation in patients with rheumatic diseases.

BACKGROUND: Studies have suggested that atrial fibrillation (AF) in patients with rheumatic diseases (RD) may be due to inflammation. AIM: To determine the highest association of AF among hospitalized RD patients and to determine morbidity and mortality associated with AF in hospitalized patients with RD. METHODS: The National inpatient sample database from October 2015 to December 2017 was analyzed to identify hospitalized patients with RD with and without AF. A subgroup analysis was performed comparing outcomes of AF among different RD. RESULTS: The prevalence of AF was 23.9% among all patients with RD (n = 3949203). Among the RD subgroup, the prevalence of AF was highest in polymyalgia rheumatica (33.2%), gout (30.2%), and pseudogout (27.1%). After adjusting for comorbidities, the odds of having AF were increased with gout (1.25), vasculitis (1.19), polymyalgia rheumatica (1.15), dermatopolymyositis (1.14), psoriatic arthropathy (1.12), lupus (1.09), rheumatoid arthritis (1.05) and pseudogout (1.04). In contrast, enteropathic arthropathy (0.44), scleroderma (0.96), ankylosing spondylitis (0.96), and Sjorgen's syndrome (0.94) had a decreased association of AF. The mortality, length of stay, and hospitalization costs were higher in patients with RD having AF vs without AF. Among the RD subgroup, the highest mortality was found with scleroderma (4.8%), followed by vasculitis (4%) and dermatopolymyositis (3.5%). CONCLUSION: A highest association of AF was found with gout followed by vasculitis, and polymyalgia rheumatica when compared to other RD. Mortality was two-fold higher in patients with RD with AF.

Radial artery spasm: reviews and updates.

Elective and emergent coronary interventions via transradial access (TRA) are been used increasingly as they carry a reduced risk of complications. Percutaneous coronary intervention via TRA may lead to radial artery spasms (RAS) that may result in prolonged procedure time, cross-over of access site, and other complications. This review article discusses the recent definitions, incidences, pathophysiology, predictive score calculator, efficacy, the safety of the radial cocktails, and treatment of the RAS.

Cardiac resynchronization therapy: A comparative analysis of mortality in African Americans and Caucasians.

BACKGROUND: Cardiac resynchronization therapy (CRT) is recommended in patients with heart failure, reduced left ventricular ejection fraction, and a prolonged QRS duration. African Americans are underrepresented in clinical trials and CRT is underutilized; consequently, the benefits and outcomes of CRT are not well-defined. METHODS: We evaluated 294 patients, determined survival using Kaplan-Meier analysis, and used Cox proportional hazards regression model to determine predictors of mortality. Propensity score-match analysis was applied to balance covariates in African Americans and Caucasians. RESULTS: The mean age for African Americans (n  =  131) and Caucasians (n  =  163) was 65 ± 12 and 70 ± 13 years (P  =  0.0003). Mortality in African Americans was 28% compared to 37% in Caucasians (P  =  0.14) over a median follow-up of 8.1 ± 0.6 years. Survival was significantly reduced in African Americans and Caucasians with a glomerular filtration rate (GFR) < 60 (6.7 ± 0.4, 95% confidence interval [CI]: 5.9-7.5 vs 8.6 ± 0.5 CI: 7.7-9.5 years, P  =  0.005), and those not treated with an aldosterone antagonist (7.1 ± 0.4, 95% CI: 6.5-7.9 vs 8.7 ± 0.6, 7.6-9.9 years, P  =  0.04), respectively. Independent predictors of mortality were a GFR <60 and low left ventricular ejection fraction. In African Americans, ischemic cardiomyopathy (ICM) and lack of therapy with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were associated with increased mortality. CONCLUSIONS: Long-term survival benefit from CRT was similar in African Americans and Caucasians. A GFR < 60 and lack of therapy with an aldosterone antagonist were associated with decreased survival. Survival also was inversely related to the number of comorbidities. In African Americans, underutilization of an ACEI or ARB, and ICM were additional factors associated with increased mortality.

Sinus Bradycardia in Habitual Cocaine Users.

Common physiological manifestations of cocaine are related to its adrenergic effects, due to inhibition of dopamine and norepinephrine uptake at the postsynaptic terminal. Few studies have documented bradycardia secondary to cocaine use, representing the antithesis of its adrenergic effects. We assessed the prevalence of sinus bradycardia (SB) in habitual cocaine users and postulated a mechanism for this effect. One hundred sixty-two patients with a history of cocaine use were analyzed and compared with age- and gender-matched controls. SB was defined as a rate of <60 beats/min and habitual cocaine use as 2 or more documented uses >30 days apart. Propensity score-matching analysis was applied to balance covariates between cocaine users and nonusers and reduce selection bias. Patients with a history of bradycardia, hypothyroidism, or concomitant beta-blocker use were excluded. Mean age of study patients was 44 ± 8 years. SB was observed in 43 of 162 (27%) cocaine users and in 9 of 149 (6%) nonusers (p = 0.0001). Propensity score-matching analysis matched 218 patients from both groups. Among matched patients SB was observed in 25 of 109 (23%) cocaine users and in 5 of 109 (5%) nonusers (p = 0.0001). Habitual cocaine use was an independent predictor of SB and associated with a sevenfold increase in the risk of SB (95% CI 2.52 to 19.74, p = 0.0002). In conclusion, habitual cocaine use is a strong predictor of SB and was unrelated to recency of use. A potential mechanism for SB may be related to cocaine-induced desensitization of the beta-adrenergic receptor secondary to continuous exposure. Symptomatic SB was not observed; thus, pacemaker therapy was not indicated.

Mortality in African-Americans Following Cardiac Resynchronization Therapy: A Single Center Experience.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves clinical outcomes and reduces mortality in heart failure patients who remain symptomatic despite optimal medical therapy. CRT trials have reported significant hemodynamic benefits, improvement in functional status, and reduced mortality and heart failure hospitalizations. However, African-American patient representation in these studies is limited thus the results may not be applicable to them. We described baseline clinical characteristics of African-American patients undergoing CRT and determined their outcomes relative to those reported in clinical trials. METHODS: We evaluated 131 African-American patients with New York Heart Association functional class II-IV heart failure undergoing CRT and determined predictors of all-cause mortality. Kaplan-Meier survival estimates and a Cox proportional hazards model determined mortality and risk of death. RESULTS: The mean age was 65 ± 12 years. Over a 6-year period, total mortality in African-Americans was 23% as compared with 29% in the MADIT-CRT trial. Increased mortality was associated with older age (hazard rate (HR) 1.04, 95% confidence interval (CI) 1.01-1.07, P=.01), ischemic cardiomyopathy (HR 2.86, 95% CI 1.36-6.04, P=.006), and absence of treatment with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (HR 2.75, 95% CI 1.30-5.80, P=.008), or beta-blocker (HR 2.56, 95% CI 0.98-6.69, P=.05). Hydralazine plus nitrate therapy was used in a small number of patients and did not influence mortality outcomes. CONCLUSION: African-Americans experience the same survival benefits from CRT as Caucasian patients reported in major clinical trials. Publication indices used to find publications listed in references: PubMed.

Biventricular paced QRS predictors of left ventricular lead locations in relation to mortality in cardiac resynchronization therapy.

BACKGROUND: Left ventricular (LV) lead location during cardiac resynchronization therapy (CRT) has influenced mortality and heart failure events; however the biventricular paced QRS morphology has not been established as a predictor of LV lead location or mortality. METHODS: We evaluated the biventricular paced QRS morphology in 306 patients undergoing CRT in relation to specific anatomic locations. A logistic regression model and Kaplan-Meier survival estimates were used to determine predictors of LV lead location and survival. RESULTS: The mean age was 68±13years. Predictors of LV lead location from anterior, lateral, and posterior segments were: absence of R in V1, QS in aVL; and R in aVL, respectively. Absence of an R in II, III, or aVF predicted an inferior site. A QS in V4-V6 differentiated apical from basal sites (p=0.01). LV pacing from sites along the middle cardiac vein revealed a higher mortality (34%), than lateral sites (20%, p=0.02). CONCLUSIONS: Biventricular paced QRS criteria were predictive of LV lead locations. The proposed algorithm enhanced the predictive accuracy of these criteria. LV pacing sites along the middle cardiac vein were associated with increased mortality.

Asymptomatic sinus bradycardia following bariatric surgery.

Approximately 121,000 bariatric surgical procedures are performed annually, and salutary effects include a reduction in cardiovascular morbidity and mortality, risk factor modification, and improvement in sympathovagal tone. There are anecdotal accounts of unexplained sinus bradycardia (SB) after significant weight loss but no systematic studies have been conducted. The purpose of this study was to determine the frequency of incident SB, its timing, and association with weight loss, clinical characteristics, and predictors. We evaluated various clinical characteristics including resting heart rate, blood pressure, body mass index (BMI), heart rate reserve (HRR), basal metabolic rate, and exercise regimen in 151 consecutive patients who underwent bariatric surgery. Multiple logistic regression analysis was performed to determine predictors of SB. Twenty-five of 137 patients (18%) experienced postoperative SB. Patients with SB had significantly greater reduction in BMI than those without bradycardia (35 ± 9.6% and 25.7 ± 13%, respectively, p = 0.002). HRR was significantly greater in patients with SB (116 ± 14 beats/min) compared with those without bradycardia (105 ± 14 beats/min, p = 0.007). Multiple logistic regression analysis revealed that the odds of developing SB were 1.96 and 1.91 and associated with the percent decrease in BMI (95% confidence interval 1.3 to 3.0, p = 0.002) or increase in HRR (95% confidence interval 1.28 to 2.85, p = 0.002), respectively. In conclusion, SB occurred 14 ± 11 months postoperatively and its predictors were the percent reduction in BMI or increase in HRR.