Does Heart Failure Mask Candida Tricuspid Endocarditis?

Infective endocarditis (IE) carries high morbidity and mortality. Although minimal in incidence, fungal causes (mostly Candida species) carry the highest mortality among all cases of infective endocarditis. We describe a rare case of a 47-year-old male with a past medical history of cerebral vascular accident (CVA), heart failure with reduced ejection fraction status post (SP) automated implantable cardioverter defibrillator (AICD) placement, paroxysmal atrial fibrillation, coronary artery disease (CAD), infective endocarditis with mitral valve replacement and tricuspid valve replacement, and pulmonary hypertension who presented to the emergency department (ED) with complaints of shortness of breath and weakness for four days. The patient was admitted to the cardiac care unit (CCU) due to persistent hypotension despite being on a continuous milrinone drip at home. The patient was initially started on antimicrobial agents for sepsis most likely secondary to pneumonia. Echocardiographic imaging showed a large vegetation on the tricuspid valve; hence, blood cultures were sent and came back positive for Candida sp. Appropriate antifungals (micafungin) were added to the medication regimen, and the patient was transferred to a tertiary hospital for surgical intervention. Patients with bioprosthetic valve replacement require regular follow-ups as this would allow providers to catch symptoms of developing endocarditis and prevent disease progression. These appointments may also decrease other risk factors for the disease, including but not limited to infected lines.

Troponin and Other Biomarker Levels and Outcomes Among Patients Hospitalized With COVID-19: Derivation and Validation of the HA2T2 COVID-19 Mortality Risk Score.

Background The independent prognostic value of troponin and other biomarker elevation among patients with coronavirus disease 2019 (COVID-19) are unclear. We sought to characterize biomarker levels in patients hospitalized with COVID-19 and develop and validate a mortality risk score. Methods and Results An observational cohort study of 1053 patients with COVID-19 was conducted. Patients with all of the following biomarkers measured-troponin-I, B-type natriuretic peptide, C-reactive protein, ferritin, and d-dimer (n=446) -were identified. Maximum levels for each biomarker were recorded. The primary end point was 30-day in-hospital mortality. Multivariable logistic regression was used to construct a mortality risk score. Validation of the risk score was performed using an independent patient cohort (n=440). Mean age of patients was 65.0±15.2 years and 65.3% were men. Overall, 444 (99.6%) had elevation of any biomarker. Among tested biomarkers, troponin-I ≥0.34 ng/mL was the only independent predictor of 30-day mortality (adjusted odds ratio, 4.38; P<0.001). Patients with a mortality score using hypoxia on presentation, age, and troponin-I elevation, age (HA2T2) ≥3 had a 30-day mortality of 43.7% while those with a score <3 had mortality of 5.9%. Area under the receiver operating characteristic curve of the HA2T2 score was 0.834 for the derivation cohort and 0.784 for the validation cohort. Conclusions Elevated troponin and other biomarker levels are commonly seen in patients hospitalized with COVID-19. High troponin levels are a potent predictor of 30-day in-hospital mortality. A simple risk score can stratify patients at risk for COVID-19-associated mortality.

Outcomes and mortality associated with atrial arrhythmias among patients hospitalized with COVID-19.

INTRODUCTION: The impact of atrial arrhythmias on coronavirus disease 2019 (COVID-19)-associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID-19. METHODS: An observational cohort study of 1053 patients with severe acute respiratory syndrome coronavirus 2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30-day mortality was assessed with multivariable analysis. RESULTS: Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared with patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B-type natriuretic peptide, C-reactive protein, ferritin and d-dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; p < .001). After adjustment for age and co-morbidities, AF/AFL (adjusted odds ratio [OR]: 1.93; p = .007) and newly detected AF/AFL (adjusted OR: 2.87; p < .001) were independently associated with 30-day mortality. CONCLUSION: Atrial arrhythmias are common among patients hospitalized with COVID-19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality.

Reduced global longitudinal strain is associated with increased risk of cardiovascular events or death after kidney transplant.

BACKGROUND: Patients with chronic kidney disease are at increased risk of cardiovascular disease (CVD). Even after kidney transplant, the rate of CVD events and death remain elevated. Early detection of patients at risk would be helpful for guiding aggressive preventive therapy. The purpose of this study was to evaluate global longitudinal strain (GLS) as a predictor of CVD events and death after kidney transplant. METHOD: Among patients with successful kidney transplant between 3/2009 and 12/2012 at our institution, 111 individuals had an echocardiogram within 6 months of the transplant. Medical records were evaluated for demographics and patient characteristics. Echocardiograms were analyzed for conventional measurements, and GLS was assessed using speckle-tracking analysis. RESULTS: The median age of the study sample was 54 years. Overall, 60% were men; 35% were non-Hispanic black, and 50% Hispanic. After a mean follow-up of 3.8 ±â€¯0.5 years, there were 21 cardiovascular events or deaths. Patients who experienced an event were older, more frequently had a history of coronary artery disease, and had higher LV filling/longitudinal diastolic annular velocity (E/e') than those who did not. GLS was significantly associated with event-free survival even after adjusting for age, sex, race-ethnicity, hypertension, diabetes, history of coronary artery disease or heart failure, and E/e'. CONCLUSION: Reduced GLS peri-transplant is significantly associated with increased CVD events or death after kidney transplant. Larger studies are required to determine the incremental predictive value of GLS over clinical and other echocardiographic parameters for adverse CVD events following renal transplantation.

Efficacy and Safety Outcomes of Direct Oral Anticoagulants and Amiodarone in Patients with Atrial Fibrillation.

BACKGROUND: Direct oral anticoagulants (DOACs) and amiodarone are widely used in the treatment of nonvalvular atrial fibrillation. The DOACs are P-glycoprotein (P-gp) and cytochrome p-450 (CYP3A4) substrates. Direct oral anticoagulant levels may be increased by the concomitant use of potent dual P-gp/CYP3A4 inhibitors, such as amiodarone, which can potentially translate into adverse clinical outcomes. We aimed to assess the efficacy and safety of drug-drug interaction by the concomitant use of DOACs and amiodarone. METHODS: We performed a systematic review of MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase, limiting our search to randomized controlled trials of patients with atrial fibrillation that have compared DOACs versus warfarin for prophylaxis of stroke or systemic embolism, to analyze the impact on stroke or systemic embolism, major bleeding, and intracranial bleeding risk in patients with concomitant use of amiodarone. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The fixed effects model was used owing to heterogeneity (I2) < 25%. RESULTS: Four trials with a total of 71,683 patients were analyzed, from which 5% of patients (n = 3212) were concomitantly taking DOAC and amiodarone. We found no statistically significant difference for any of the clinical outcomes (stroke or systemic embolism [RR 0.85; 95% CI, 0.67-1.06], major bleeding [RR 0.91; 95% CI, 0.77-1.07], or intracranial bleeding [RR 1.10; 95% CI, 0.68-1.78]) among patients taking DOAC and amiodarone versus DOAC without amiodarone. CONCLUSION: On the basis of the results of this meta-analysis, co-administration of DOACs and amiodarone, a dual P-gp/CYP3A4 inhibitor, does not seem to affect efficacy or safety outcomes in patients with atrial fibrillation.

Leaving tissue associated with infrequent intracranial EEG seizure onsets is compatible with post-operative seizure freedom.

Identify seizure onset electrodes that need to be resected for seizure freedom in children undergoing intracranial electroencephalography recording for treatment of medically refractory epilepsy. All children undergoing intracranial electroencephalography subdural grid electrode placement at the Children's Hospital of Philadelphia from 2002-2008 were asked to enroll. We utilized intraoperative pictures to determine the location of the electrodes and define the resection cavity. A total of 15 patients had surgical fields that allowed for complete identification of the electrodes over the area of resection. Eight of 15 patients were seizure free after a follow up of 1.7 to 8 yr. Only one seizure-free patient had complete resection of all seizure onset associated tissue. Seizure free patients had resection of 64.1% of the seizure onset electrode associated tissue, compared to 35.2% in the not seizure free patients (p=0.05). Resection of tissue associated with infrequent seizure onsets did not appear to be important for seizure freedom. Resecting ≥ 90% of the electrodes from the predominant seizure contacts predicted post-operative seizure freedom (p=0.007). The best predictor of seizure freedom was resecting ≥ 90% of tissue involved in majority of a patient's seizures. Resection of tissue under infrequent seizure onset electrodes was not necessary for seizure freedom.

Interictal EEG spikes identify the region of electrographic seizure onset in some, but not all, pediatric epilepsy patients.

PURPOSE: The role of sharps and spikes, interictal epileptiform discharges (IEDs), in guiding epilepsy surgery in children remains controversial, particularly with intracranial electroencephalography (IEEG). Although ictal recording is the mainstay of localizing epileptic networks for surgical resection, current practice dictates removing regions generating frequent IEDs if they are near the ictal onset zone. Indeed, past studies suggest an inconsistent relationship between IED and seizure-onset location, although these studies were based upon relatively short EEG epochs. METHODS: We employ a previously validated, computerized spike detector to measure and localize IED activity over prolonged, representative segments of IEEG recorded from 19 children with intractable, mostly extratemporal lobe epilepsy. Approximately 8 h of IEEG, randomly selected 30-min segments of continuous interictal IEEG per patient, were analyzed over all intracranial electrode contacts. RESULTS: When spike frequency was averaged over the 16-time segments, electrodes with the highest mean spike frequency were found to be within the seizure-onset region in 11 of 19 patients. There was significant variability between individual 30-min segments in these patients, indicating that large statistical samples of interictal activity were required for improved localization. Low-voltage fast EEG at seizure onset was the only clinical factor predicting IED localization to the seizure-onset region. CONCLUSIONS: Our data suggest that automated IED detection over multiple representative samples of IEEG may be of utility in planning epilepsy surgery for children with intractable epilepsy. Further research is required to better determine which patients may benefit from this technique a priori.

Topiramate and adrenocorticotropic hormone (ACTH) as initial treatment for infantile spasms.

Historically, adrenocorticotropic hormone was used as a first-line treatment for infantile spasms; however, there has been increasing use of topiramate as initial therapy. Here, we report a retrospective study of adrenocorticotropic hormone (ACTH) and topiramate as initial treatment for infantile spasms. The neurology patient database at the Children's Hospital of Philadelphia was searched using the International Classification of Diseases, Ninth Revision code for infantile spasms, and 50 patients were randomly chosen for chart review. We identified 31 patients receiving either adrenocorticotropic hormone or topiramate monotherapy (adrenocorticotropic hormone n = 12, topiramate n = 19) as a first-line treatment for infantile spasms. A total of 26 patients were symptomatic and 5 cryptogenic. Six patients treated with adrenocorticotropic hormone had resolution of clinical spasms and hypsarrhythmia within a month, but 3 relapsed. Of the 19 patients treated with topiramate, 4 patients eventually, though over a period of 0, 1, 8, or 69 months, had resolution of spasms and hypsarrhythmia.