Predictors of Polymorphic Ventricular Tachycardia and Ventricular Fibrillation in Patients With Takotsubo Syndrome.

Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are life-threatening complications of takotsubo syndrome (TTS). Data regarding risk factors for PVT/VF based on the TTS variant are lacking. This study aimed to identify demographic and clinical factors associated with PVT and VF in patients with TTS. Patients meeting the InterTak criteria for TTS between 2010 and 2022 were retrospectively identified. The occurrence of PVT/VF with each risk factor was analyzed using logistic regression. Sensitivity analysis was performed to assess the interaction between risk factors. PVT/VF occurred in 27 of 296 patients with TTS (9.1%). Patients with PVT/VF were younger (52 vs 62 years, p = 0.019) and more frequently used stimulants in the 4 weeks before admission (22.2% vs 8.2%, odds ratio [OR] 3.20, p = 0.023). All PVT/VF occurred within 24 hours of hospitalization. An initial QTc threshold of 490 ms had the highest sensitivity and specificity for the occurrence of PVT/VF (area under the curve = 0.687). Patients with PVT/VF were more likely to have a QTc >490 ms on admission (55.6% vs 18.7%, OR 5.45, p <0.01), apical variant TTS (78% vs 56%, OR 2.69, p = 0.038), and an admission ejection fraction <30% (63% vs 41.5%, OR 2.39, p = 0.032); each factor was independently associated with PVT/VF irrespective of QTc duration on sensitivity analysis. In conclusion, nearly 1 in 10 patients with TTS had PVT/VF. A QTc >490 ms, recent stimulant use, apical variant TTS, and severe left ventricular systolic dysfunction on admission are associated with higher PVT/VF risk, with the first 24 hours being a high-risk period.

Use of SAMe-TT2R2 in a racially diverse anticoagulation clinic: prediction of optimal anticoagulation.

The SAMe-TT2R2 score predicts optimal long-term oral Vitamin K Antagonist (VKA) anticoagulation for homogenous Caucasian and homogenous Asian populations for non-valvular atrial fibrillation but at different score thresholds. The score that predicts optimal VKA anticoagulation in significantly diverse populations for multiple indications for systemic anticoagulation has not been reported. We determined whether optimal VKA anticoagulation is predicted by SAMe-TT2R2 score in a diverse inner-city population for non-valvular atrial fibrillation (NVAF), unprovoked venous and pulmonary thromboembolic disease (VTE), mechanical prosthetic heart valves and all other indications. All patients on long term VKA's that attended an inner-city anticoagulation clinic between February 2016 and October 2017 were included in this study. Eligible patients were grouped according to oral anticoagulation indication: (1) NVAF, (2) VTE, (3) prosthetic valves and (4) other indications. Each patient's SAMe-TT2R2 score and percent time of INR in the therapeutic range (TTR) was calculated with optimal international normalized ratio (INR) control defined as TTR ≥ 65%. The correlation between SAMe-TT2R2 score and TTR was determined by logistic regression for each oral anticoagulant indication. Receiver operating characteristic curves were then used to identify the best cutoff for prediction of ≥ 65% TTR. Of 316 patients meeting study criteria, 54% were non-Caucasian and there was a significant negative correlation between the SAMe-TT2R2 score and TTR (coefficient - 0.35, P < 0.0001) for all patients. A SAMe-TT2R2 score < 4 was identified as the best threshold for predicting optimal TTR (Youden's J-statistics = 0.238) with accuracy and positive likelihood ratio of 63.4% and 1.73, respectively. The SAMe-TT2R2 score predicts optimal VKA anticoagulation for systemic anticoagulation for multiple indications in a diverse urban population at a higher score than the original report for non-valvular atrial fibrillation of a cohort where < 10% non-Caucasians.

Rapidly Progressive and Catastrophic Calciphylaxis After Mechanical Valve Replacement: An Anticoagulation Dilemma.

Warfarin is the only approved anticoagulant after mechanical valve replacement, but it is a well described risk factor for calciphylaxis among patients with end-stage kidney disease. Our patient with end-stage kidney disease rapidly developed calciphylaxis after dual mechanical valve replacement in association with warfarin initiation, posing significant challenges in clinical management and a fatal outcome. (Level of Difficulty: Intermediate.).

Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial.

BACKGROUND: Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. OBJECTIVES: In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. METHODS: In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. RESULTS: Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35). CONCLUSIONS: In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).

Meta-Analysis Comparing Torsemide Versus Furosemide in Patients With Heart Failure.

Although torsemide's oral bioavailability and half-life theoretically render it a more efficient diuretic than furosemide, the clinical outcomes of torsemide compared with furosemide remain unclear. We performed a systematic review and meta-analysis, including all published studies that compared torsemide and furosemide use in heart failure patients from January 1996 through August 2019. Nineteen studies (9 randomized control trials [RCTs] and 10 observational studies) with a total of 19,280 patients were included. During a mean follow-up duration of 15 months, torsemide was associated with a numerically lower risk of hospitalization due to heart failure (10.6% vs 18.4%; odds ratio [OR] 0.72, 95% confidence interval [CI] [0.51, 1.03], p = 0.07, I2 = 18%; number needed to treat [NNT] = 23) compared with furosemide. Torsemide was associated with statistically significant more improvement in functional status from New York Heart Association (NYHA) class III/IV to I/II (72.5% vs 58%; OR 2.32, 95% CI (1.32, 4.1), p = 0.004, I2 = 27%; NNT = 5) and lower risk of cardiac mortality (1.5% vs 4.4%; OR 0.37, 95% CI (0.20, 0.66), p <0.001, I2 = 0%, NNT = 40) compared with furosemide. However, there was no difference in all-cause mortality or medication side effects between the 2 groups. In conclusion, compared with furosemide, torsemide use was associated with significant more improvement in functional status and lower cardiac mortality; and numerically fewer hospitalizations in patients with heart failure.

Pylephlebitis presenting as spontaneous coronary sinus thrombosis: a case report.

BACKGROUND: Coronary sinus thrombosis is a rare phenomenon. When identified, it most often is a complication of infective endocarditis or procedural intervention. We present an unusual and unreported case of spontaneous coronary sinus thrombosis as embolic sequela of an intra-abdominal infectious process. CASE PRESENTATION: We report a case of a 61-year-old white woman with a history of end-stage renal disease on hemodialysis, paroxysmal atrial fibrillation not on long-term systemic anticoagulation, and history of recurrent diverticulitis that presented with acute onset abdominal pain and nausea. Computed tomography of her abdomen and pelvis with intravenous contrast was negative for acute intra-abdominal pathology, but incidentally identified an oval-shaped filling defect at the ostium of the coronary sinus suspicious for thrombus or mass which was confirmed on subsequent transesophageal echocardiogram. In light of her concomitant transaminitis but otherwise negative workup, the mass was believed to be thromboembolic in nature, originating within the hepatic venous system as a manifestation of recurrent diverticulitis with associated pylephlebitis and ultimately lodging into the coronary sinus. With the newly detected thrombus and history of paroxysmal atrial fibrillation, she was started on warfarin for therapeutic systemic anticoagulation that resolved her clot by 3-month follow up. CONCLUSIONS: Although coronary sinus thrombosis is rare, a high index of suspicion and close scrutiny of the venous system in patients with intra-abdominal infectious processes would prevent delay in management of this potentially serious complication. The discussion of this case highlights the anatomy of the cardiac venous system, the pathophysiology of thrombus formation, and the utility of transesophageal echocardiography in confirming a diagnosis and assessing treatment efficacy.

Mitral Valve Perforation in Libman-Sacks Endocarditis: A Heart-Wrenching Case of Lupus.

Libman-Sacks (LS) endocarditis is one of the most common cardiac manifestations of systemic lupus erythematosus. Rarely, however, it can lead to serious complications, including severe valvular regurgitation or superimposed bacterial endocarditis. We describe the initial diagnostic challenges, clinical course, imaging studies and histopathological findings of a patient who presented with life-threatening lupus complicated by hemoptysis and respiratory failure secondary to a rare complication of LS endocarditis, acute mitral valve perforation. We review the current literature on valve perforation in the setting of LS endocarditis. In conclusion, although the disease is often asymptomatic and hemodynamically insignificant, it can result in serious and potentially fatal complications secondary to valve perforation, which may demand emergency surgical management.

Massive interventricular septal aneurysm and stroke in a healthy young patient: guilt by association?

Aneurysm of the membranous interventricular septum is an uncommon cardiac defect that is, on rare occasions, associated with embolic stroke. We describe here the case of an otherwise healthy, 41-year-old man who presented to the hospital with acute-onset confusion and left-sided body weakness attributed to a right middle cerebral artery ischemic stroke. He experienced a nearly complete resolution of deficits following systemic thrombolytic therapy. After an extensive workup, the presumed mechanism of stroke was a thromboembolus that originated in a massive aneurysm of the patient's membranous interventricular septum. Due to a perceived risk of surgical morbidity, the patient was managed conservatively with anticoagulation. He denied further events and reported nearly full function at follow-up.

Two-dimensional strain profiles in patients with physiological and pathological hypertrophy and preserved left ventricular systolic function: a comparative analyses.

OBJECTIVE: This study was designed to examine the utility of two-dimensional strain (2DS) or speckle tracking imaging to typify functional adaptations of the left ventricle in variant forms of left ventricular hypertrophy (LVH). DESIGN: Cross-sectional study. SETTING: Urban tertiary care academic medical centres. PARTICIPANTS: A total of 129 subjects, 56 with hypertrophic cardiomyopathy (HCM), 34 with hypertensive left ventricular hypertrophy (H-LVH), 27 professional athletes with LVH (AT-LVH) and 12 healthy controls in sinus rhythm with preserved left ventricular systolic function. METHODS: Conventional echocardiographic and tissue Doppler examinations were performed in all study subjects. Bi-dimensional acquisitions were analysed to map longitudinal systolic strain (automated function imaging, AFI, GE Healthcare, Waukesha, Wisconsin, USA) from apical views. RESULTS: Subjects with HCM had significantly lower regional and average global peak longitudinal systolic strain (GLS-avg) compared with controls and other forms of LVH. Strain dispersion index, a measure of regional contractile heterogeneity, was higher in HCM compared with the rest of the groups. On receiver operator characteristics analysis, GLS-avg had excellent discriminatory ability to distinguish HCM from H-LVH area under curve (AUC) (0.893, p<0.001) or AT-LVH AUC (0.920, p<0.001). Tissue Doppler and LV morphological parameters were better suited to differentiate the athlete heart from HCM. CONCLUSIONS: 2DS (AFI) allows rapid characterisation of regional and global systolic function and may have the potential to differentiate HCM from variant forms of LVH.

Usefulness of microalbuminuria in patients with the metabolic syndrome to predict subclinical atherosclerosis and cardiovascular disease outcomes.

The clinical implications of microalbuminuria (MA) in nondiabetic persons with the metabolic syndrome (MS) are largely unknown. The present post hoc analysis of the Multiethnic Study of Atherosclerosis (MESA) included 5,809 nondiabetic persons with no history of cardiovascular disease aged 45 to 84 years. The study population was divided according to the presence or absence of MS and MA into 4 study groups: no MS and no MA, MA only, MS only, and MS plus MA. The measurements included markers of systemic inflammation, subclinical atherosclerosis, left ventricular mass index, composite and individual cardiovascular end points, and all-cause mortality. Prospective and cross-sectional analyses were performed to ascertain the association of study groups with these covariates. The MS plus MA group showed a consistently stronger association with the markers of systemic inflammation, subclinical atherosclerosis, and most clinical end points compared to the other study groups. In conclusion, stratification by MA can help identify a high-risk subset of nondiabetic patients with the MS.

Usefulness of intravenously administered fluid replenishment for detection of patent foramen ovale by transesophageal echocardiography.

Patent foramen ovale (PFO) is associated with cryptogenic stroke, migraine headache, decompression sickness, and platypnea-orthodeoxia syndrome. Patients undergoing transesophageal echocardiography are often hypovolemic from preprocedural fasting and might not demonstrate right to left shunting owing to insufficient right atrial pressure generation, despite provocative maneuvers. We hypothesized that volume replenishment with saline loading could potentially unmask a PFO by favorably modulating the interatrial pressure gradient. Our study sought to examine the role of pre- or intraprocedural intravenous fluid replenishment on PFO detection during transesophageal echocardiography. A total of 103 patients were enrolled. An initial series of bubble injections was performed unprovoked and then with provocative maneuvers such as the Valsalva maneuver and coughing. The patients were then given a rapid 500 ml saline bolus, and the same sequence of bubble injections was repeated. The presence, type, and magnitude of the right to left shunts were noted before and after the saline bolus. The detection rate of PFO increased from 10.6% to 26.2% after saline loading without any provocative maneuvers. When combined with provocative maneuvers (Valsalva or cough), saline loading improved the detection rate from 17.4% to 32.0%. Overall, from amongst the 103 enrolled patients, saline bolusing resulted in a de novo diagnosis of PFO in 15 patients, atrial septal aneurysm in 15, PFO coexisting with an atrial septal aneurysm in 10, and pulmonary arteriovenous fistula in 5 patients. In conclusion, saline infusion in appropriately selected patients during transesophageal echocardiography significantly enhances the detection of PFOs and pulmonary arteriovenous fistulas.

Predictors of stroke in patients with severe systolic dysfunction in sinus rhythm: role of echocardiography.

BACKGROUND: Congestive heart failure in sinus rhythm ranks second after atrial fibrillation (AF) among cardiogenic risk-factors for stroke. Clinical and echocardiographic predictors of stroke in this high-risk population remain poorly defined. METHODS: Retrospective screening of 1886 consecutive patients with severe systolic dysfunction (LVEF ≤35%) at a tertiary medical center echocardiography database (Nov 2005-Sep 2008) identified 83 patients in sinus rhythm with cardioembolic stroke. Patients with AF on follow-up, prosthetic valve, ventricular arrhythmia and lack of consensus between reviewing neurologists were excluded (n=10). Consecutive age and gender-matched controls in sinus rhythm formed GpII (n=73). RESULTS: The incidence of stroke was 3.9% (73/1886) over 35 months in this study. There were no significant differences in prevalence of established clinical risk-factors for stroke. There was a significantly higher prevalence of LV non-compaction (p=0.02), aneurysm (p<0.01), spontaneous echo-contrast (p<0.01) and pulmonary hypertension (p<0.001) in GpI. CONCLUSIONS: LV non-compaction, aneurysm, spontaneous echo-contrast and pulmonary hypertension are associated with an increased risk of stroke. While anticoagulation of these high-risk subgroups appears reasonable, further study in a prospective randomized clinical trial merits consideration.

WITHDRAWN: Clinical and echocardiographic predictors of cerebrovascular events and left ventricular thrombus in patients with severe systolic dysfunction in sinus rhythm.

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