A 5-year survivor of endarterectomy for sclerosing undifferentiated intimal sarcoma of the pulmonary artery: Importance of clinical suspicion and careful histologic evaluation.

We present a diagnostically challenging case of intimal sarcoma of the pulmonary artery (PA) due to the histologic finding of a sclerosing appearance with no appreciable spindle/pleomorphic cell proliferation. Initial endarterectomy specimens were composed of sclerosing extracellular matrix with a few bland cells, some recanalization, and fibrin thrombi, impeding the confirmation of intimal sarcoma as these findings were also consistent with chronic thromboembolic pulmonary hypertension. However, the patient experienced recurrence 5 years later, and the second endarterectomy specimens revealed more firm and solid mass and the proliferation of atypical spindle/pleomorphic cells within a myxomatous matrix in the distal PA, leading to the definitive diagnosis of undifferentiated intimal sarcoma of the PA. The archival specimens from the endarterectomy confirmed intense MDM2 expression by immunohistochemistry, suggesting its role as a potential diagnostic marker for intimal sarcoma. This case highlights that prominent sclerosing extracellular matrix with very few atypical cells should raise the possibility of intimal sarcoma of the PA and that high index of suspicion, generous sampling, and ancillary tests are critical for accurate diagnosis. In this case, the tumor was incidentally removed by endarterectomy, resulting in 5 years of survival.

Outcomes in novel hospital-at-home model for patients with COVID-19: a multicentre retrospective cohort study.

BACKGROUND: Hospital-at-home (HaH) care has been proposed as an alternative to inpatient care for patients with coronavirus disease (COVID-19). Previous reports were hospital-led and involved patients triaged at the hospitals. To reduce the burden on hospitals, we constructed a novel HaH care model organized by a team of local primary care clinics. METHODS: We conducted a multicentre retrospective cohort study of the COVID-19 patients who received our HaH care from 1 January to 31 March 2022. Patients who were not able to be triaged for the need for hospitalization by the Health Center solely responsible for the management of COVID-19 patients in Osaka city were included. The primary outcome was receiving medical care beyond the HaH care defined as a composite outcome of any medical consultation, hospitalization, or death within 30 days from the initial treatment. RESULTS: Of 382 eligible patients, 34 (9%) were triaged for hospitalization immediately after the initial visit. Of the remaining 348 patients followed up, 37 (11%) developed the primary outcome, while none died. Obesity, fever, and gastrointestinal symptoms at baseline were independently associated with an increased risk of needing medical care beyond the HaH care. A further 129 (37%) patients were managed online alone without home visit, and 170 (50%) required only 1 home visit in addition to online treatment. CONCLUSIONS: The HaH care model with a team of primary care clinics was able to triage patients with COVID-19 who needed immediate hospitalization without involving hospitals, and treated most of the remaining patients at home.

Value of estimated right ventricular filling pressure in predicting cardiac events in chronic pulmonary arterial hypertension.

BACKGROUND: Right ventricular (RV) filling pressure can be estimated using tissue Doppler imaging (TDI) from the tricuspid lateral annulus, but few data are available on the usefulness of Doppler-derived RV filling pressure in predicting the prognosis of chronic pulmonary arterial hypertension (PAH). METHODS: In 50 consecutive patients with PAH, TDI was performed within 24 hours of right-sided catheterization to measure early diastolic myocardial velocity at the tricuspid lateral annulus (E(a)) and early diastolic tricuspid inflow (E). The tricuspid E/E(a) ratio was calculated and compared with the invasive hemodynamic variables. Cardiac events were defined as cardiac death or rehospitalization due to RV failure. RESULTS: Mean right atrial pressure (RAP) averaged 6 +/- 5 mm Hg (range, 1-25 mm Hg). E/E(a) correlated positively with mean RAP (r = 0.80, P < .001), irrespective of RV systolic function. We divided patients into group A with cardiac events (n = 19) and group B without events (n = 31) in a mean follow-up period of 14 months. Plasma brain natriuretic peptide level and E/E(a) were significantly higher in group A than in group B (349 +/- 310 pg/dL vs 129 +/- 136 pg/dL, P = .001; 7.0 +/- 3.2 vs 4.5 +/- 1.9, P = .004, respectively), whereas mean pulmonary artery pressure did not differ significantly. In a multivariate model, E/E(a) remained predictive for cardiac events (hazard ratio 1.227; 95% confidence interval, 1.042-1.444; P = .014). An E/E(a) cutoff value of 6.8 discriminated cases with cardiac events with a sensitivity of 42% and specificity of 97% (area under the curve 0.71). CONCLUSION: The tricuspid E/E(a) ratio provides a reliable estimation of RV filling pressure and predicts cardiac events in patients with PAH.

Inverted Takotsubo cardiomyopathy masking acute myocardial infarction.

We report a case of inverted Takotsubo cardiomyopathy masking acute myocardial infarction. In this case, echocardiography on admission showed left ventricular mid and basal akinesis and apical hyperkinesis compatible with an inverted Takotsubo contractile pattern. In the subacute phase, however, he was suspected of having acute myocardial infarction by serial changes of cardiac enzymes. After 8 days of admission, echocardiography showed normalization of the left ventricular contraction, except the inferior wall which was compatible with inferior myocardial infarction. Subsequent myocardial scintigraphy confirmed the diagnosis. It is important to recognize that inverted Takotsubo cardiomyopathy may mask acute myocardial infarction when they occur simultaneously.