Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis.

BACKGROUND: Calcific aortic stenosis is the principal indication for transcatheter aortic valve replacement (TAVR). Comorbid mitral annular calcification (MAC) is often present in patients undergoing TAVR. Limited data exist on the impact of MAC on TAVR outcomes. We conducted a systematic review and meta-analysis to explore the effects of MAC and concomitant mitral valve dysfunction (MVD) on TAVR outcomes. METHODS: A comprehensive literature review was conducted using PubMed, Embase, Google Scholar, ClinicalTrials.gov, Scopus, and OVID for studies until March 20, 2023. Using the random-effects Mantel-Haenszel method, we calculated pooled risk ratios (RRs) and their corresponding 95 % confidence intervals (CIs) for all dichotomous variables. RESULTS: Six studies comprising 5822 patients (2541 with MAC [severe MAC (>4 mm thickness) 583; non-severe MAC 1958; 400 with MVD; and 1071 without MVD], 3281 without MAC) met inclusion criteria. At 30 days and 1 year, no significant differences were observed between the overall MAC and no MAC groups in terms of mortality, stroke, and permanent pacemaker implantation. However, MAC with MVD was associated with a higher risk of all-cause mortality compared to MAC without MVD at 30 days (RR = 3.43, 95 % CI 2.04-5.76, P < 0.00001) and at 1 year (RR = 2.44, 95 % CI 1.85-3.20, P < 0.00001). Moreover, the risk of cardiovascular mortality was higher in patients with MAC and MVD compared to those with MAC alone (RR = 2.77, 95 % CI 1.89-4.06, P < 0.00001). Additionally, patients with severe MAC had a higher risk of major bleeding at 30 days compared to the non-severe MAC group (RR = 1.33, 95 % CI 1.04-1.69, P = 0.02). CONCLUSION: TAVR appears to be safe in patients with non-severe MAC, but severe MAC is associated with a higher risk of major bleeding and concomitant MVD increases the mortality risk in patients undergoing TAVR.

Left bundle branch area pacing vs biventricular pacing for cardiac resynchronization: A systematic review and meta-analysis.

Background: Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF). Objective: The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP. Methods: We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. Results: We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, P < .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, P < .0001), improvement in New York Heart Association functional class (SMD -0.44, 95% CI -0.65 to -0.23, P < .0001), QRS duration reduction (SMD -0.90, 95% CI -1.14 to -0.66, P < .00001), left ventricular end-diastolic diameter reduction (SMD -0.31, 95% CI -0.57 to -0.05, P = .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, P < .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, P = .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD -0.94, 95% CI -1.42 to -0.47, P < .0001) and lower pacing threshold at implantation (SMD -1.03, 95% CI -1.32 to -0.74, P < .00001) and at 6 months (SMD -1.44, 95% CI -2.11 to -0.77, P < .0001) as compared with BiVP. Conclusion: Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.

Bivalvular infective endocarditis complicated by perivalvular abscess and aorto-right atrium fistula.

Infective endocarditis caused by Pseudomonas aeruginosa in patients without a history of intravenous drug abuse and endovascular procedures is rare. We present a middle-aged man with fever, chills, night sweats and dyspnoea for 2 weeks. Physical examination and blood cultures were drawn, and the patient was empirically started on antibiotics. Unfortunately, the patient experienced progressive clinical deterioration requiring endotracheal intubation and vasopressor support. Transthoracic echocardiogram followed by transesophageal echocardiogram was performed that showed bicuspid aortic valve, severe aortic regurgitation, membranous ventricular septal defect, vegetations on aortic and tricuspid valves, dilated aortic root, and a fistula between the aorta and right atrium. The patient underwent emergent aortic valve and aortic root replacement along with tricuspid commissuroplasty and ventricular septal defect (VSD) closure. Later, intraoperative tissue cultures grew P. aeruginosa, and antipseudomonal antibiotic coverage was added. This case highlights that P. aeruginosa endocarditis can occur without risk factors and can lead to fatal cardiovascular complications.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

Outcomes of Heart Failure Hospitalizations in Adult Patients With Coarctation of Aorta: Report From National Inpatient Sample.

Coarctation of aorta (CoA) is a common congenital anomaly which portends patients to early diastolic and systolic heart failure. In this retrospective cohort study, we aimed to evaluate the impact of CoA on heart failure hospitalization. Using the national inpatient sample, the study compared the outcomes of heart failure hospitalization between patients with and without CoA. We noted increasing prevalence of CoA related heart failure admissions over the last decade. Heart failure patients with CoA were younger (mean age 57 vs 71.6 years, P < 0.001), had a longer length of stay (7.4 vs 5.4 days, P < 0.001), and a higher incidence of cardiogenic shock (6.5% vs 2.1%, P = 0.001). However, there was no statistically significant difference in in-hospital mortality (OR 1.45, 95% CI: 0.58, 3.62, P = 0.421) between both groups. These findings demonstrate that CoA increase healthcare resource utilization in patients admitted with heart failure without any significant increase in in-hospital mortality.

Myopericarditis Following the Third Dose of COVID-19 mRNA Vaccination: A Case Report.

Coronavirus disease 2019 (COVID-19) mRNA vaccine-related cases of pericarditis and myocarditis have been reported infrequently. Most of the patients usually present within a week of the vaccine, and on average, most of the cases were reported after the second dose of vaccine within two to four days. Chest pain was the most common presentation, and fever and shortness of breath were the other commonly reported symptoms. The patients can have positive cardiac markers and electrocardiogram (EKG) changes, and the cases can be mistaken for cardiac emergencies. We present a 17-year-old male patient with sudden onset substernal chest pain for two days who got the third dose of the Pfizer-BioNTech mRNA vaccine within 24 hours prior. EKG was remarkable for diffuse ST elevations, and troponins were elevated. Later, the cardiac magnetic resonance imaging confirmed the findings of myopericarditis. The patient was treated with colchicine and non-steroidal anti-inflammatory drugs (NSAIDs), completely recovered, and is doing fine to date. This case hights that post-vaccine myocarditis can be mistaken and early diagnosis and management can prevent unnecessary interventions.

Post-Transcatheter Aortic Valve Replacement Infective Endocarditis Leading to Mitral Anterior Leaflet Perforation: A Case Report.

Transcatheter aortic valve replacement(TAVR)-related infective endocarditis is a rare but fatal complication that can lead to mitral valve perforation. The clinical presentation usually includes rapidly progressive heart failure and mitral regurgitation. Transesophageal echocardiogram (TEE) is considered superior to transthoracic echocardiogram (TTE) in delineating the diagnosis of mitral valve perforation. We present a case of a 75-year-old female who had a TAVR for severe aortic stenosis three years ago and presented with new-onset atrial fibrillation and developed rapidly progressive acute decompensated heart failure. A TTE showed echogenic vegetation of the mitral valve with a perforated mitral anterior leaflet and mitral regurgitation. The blood cultures grew Group B Streptococcus, and our patient lacked the risk factors for infective endocarditis, including alcoholism, chronic liver disease, pregnancy, immunosuppression, or malignancy. This article highlights infective endocarditis with an uncommon pathogen in a patient with a prior TAVR that leads to the fatal complication of mitral valve perforation.

Gas in the myocardium: a fatal presentation of Clostridium perfringens: a case report.

Background: Clostridium perfringens is a well-known cause of gas gangrene with a very high mortality rate. Multiple cases of internal organs have been reported in the literature; however, non-traumatic spontaneous gas gangrene due to C. perfringens with solely cardiac involvement in a patient without any risk factors has not been reported before. Case Summary: A 52-year-old male presented to the emergency department with chest pain and exertional dyspnoea for three days. The patient was haemodynamically stable initially, and the physical examination was unremarkable. Initial laboratory workup revealed elevated D-dimer and troponin levels. Computerized tomography (CT) of the chest was negative for pulmonary embolism but showed a hypodense focus in the cardiac silhouette. Acute coronary syndrome protocol was initiated; however, invasive cardiac workup was negative. The patient had rapid clinical deterioration with development of respiratory failure, shock, and multiorgan failure within 24 h. A transesophageal echocardiogram demonstrated an abnormal echogenic focus, corresponding to CT chest area. Despite aggressive treatment, the patient passed away within 36 h. Later, the patient's blood culture grew C. perfringens. A limited autopsy showed an abscess cavity in the interventricular septum, pathology of which revealed acute myocarditis and fibrinous pericarditis. Discussion: Unlike other reported cases of C. perfringens with cardiac abscess, our patient had no known risk factors, and no other organs were involved. We conclude from this case that an air focus on the CT scan in the myocardium can be suggestive of a spontaneous gas gangrene of the myocardium, and the patients should be treated accordingly.

Unilateral developmental absence of internal carotid artery with contralateral middle cerebral artery occlusion.

PURPOSE: Developmental absence of the internal carotid artery (ICA) is a rare congenital anomaly that results from an insult to the third aortic arch or dorsal aorta during early embryogenesis. Patients are often asymptomatic and are diagnosed incidentally during imaging to investigate neurological complaints. METHODS: We report a rare finding of an absent ICA during a workup of stroke in a middle-aged patient. RESULTS: CT brain perfusion (CTP) and CT angiography (CTA) revealed the right middle cerebral artery (MCA) thrombotic stroke with the demonstration of contralateral left ICA absence. The patient showed spontaneous recovery, and no thrombolysis or neurointervention was considered. CONCLUSIONS: This article highlights the importance of screening the head CT on bone window settings in case of the non-visualization of ICA to differentiate congenital absence from a steno-occlusive disease. It also illustrates the role of Magnetic resonance imaging (MRI) and MR Angiography (MRA) in demonstrating further possible vascular anomalies, structural brain malformations, and collateral circulation.

Complete Recovery of an Occluded Coronary Artery Secondary to Spontaneous Coronary Artery Dissection With Medical Management in a Young Patient Presenting With Acute Coronary Syndrome.

Spontaneous coronary artery dissection (SCAD) is defined as a tear in the coronary arterial wall. The clinical presentation is similar to acute coronary syndrome (ACS); however, most of the patients are usually younger and do not have typical risk factors such as atherosclerosis. In addition, the management of SCAD varies from case to case unlike that of ACS due to atherosclerotic plaque rupture; therefore, recognizing and treating it appropriately is crucial. We present a case of a 47-year-old female who presented with typical clinical findings of ACS and was diagnosed with occlusion of the left anterior descending coronary artery due to SCAD on emergent coronary angiography. The patient was treated with medical management only, and a repeat coronary angiography showed complete healing of the vessel wall after six weeks. This article highlights that early diagnosis, recognition, and medical management of SCAD can prevent unnecessary invasive intervention.

Mycobacterium chimaera lung infection and empyema in a patient without cardiopulmonary bypass.

Mycobacterium chimaera is a nontuberculous mycobacterium that belongs to the Mycobacterium avium complex. Invasive infections are very rare and have been associated with contaminated heater-cooler water systems used during cardiopulmonary bypass. There is usually a long latency period and patients have nonspecific symptoms that can result in a delayed diagnosis or misdiagnosis. We report a case of M. chimaera infection in a man who presented with worsening shortness of breath and was found to have pleural effusion. The patient did not have any history of cardiopulmonary bypass surgery, which raises concerns about community spread of this rare infection and needs further investigation in the general population. Furthermore, he had a history of sarcoidosis and was on immunosuppressive medications, which might suggest that immunosuppressed patients can acquire this infection without the described risk factors.

Postpartum HELLP syndrome complicated with large subcapsular liver hematoma.

Subcapsular hematoma of the liver is a potentially fatal complication of pregnancy-related hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. In turn, HELLP syndrome is one of the most critical complications of preeclampsia. We present a case of a 31-year-old woman who developed a subcapsular liver hematoma in the postpartum period secondary to HELLP syndrome. The diagnosis was made based on the clinical features, radiological investigation, and laboratory values. She was managed with fluids, intravenous steroids, and rigorous monitoring in the intensive care unit before being moved to a tertiary care center with hepatic surgery and interventional radiology capabilities.

Meta-analysis comparing the efficiency of high-flow nasal cannula versus low-flow nasal cannula in patients undergoing endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) identifies and treats pancreatic and biliary diseases. We conducted a systematic review and meta-analysis examining relevant papers in five databases to examine the frequency of hypoxia throughout the surgery and the lowest oxygen saturation level in patients under sedation. Our meta-analysis included three randomized controlled trials with 390 participants, 196 in the high-flow oxygen (HFNC) group and 194 in the low-flow oxygen (LFNC) group. Their ages ranged from 65.3 to 79 years. The pooled effect estimate showed that HFNC decreased the incidence of hypoxia during the procedure when compared to LFNC (odds ratio -0.84; 95% confidence interval [CI] -1.65, -0.02; P = 0.04), and the mean of lowest oxygen saturation in patients during sedation was significantly lower in LFNC compared to HFNC (mean difference 2.34; 95% CI 1.35, 3.32; P = 0.001). The pooled effect estimate showed that the HFNC group had a lower incidence rate of jaw thrusting adverse events during anesthesia than the LFNC group (risk difference -0.12; 95% CI -0.21, -0.04; P = 0.001). In summary, HFNC systems reduced the incidence of hypoxia for patients undergoing ERCP and had a higher mean lowest oxygen saturation during sedation.

Bilateral Primary Adrenal B-Cell Lymphoma Diagnosed by Workup for Primary Adrenal Deficiency.

Primary adrenal lymphoma (PAL) often occurs bilaterally and is a rare malignancy of old age. Workup for primary adrenal insufficiency often unmasks this underlying grave pathology. In this article, we present a case of a 73-yearold patient who presented with features of primary adrenal insufficiency and renal colic. Diagnostic abdominal imaging revealed bilateral suprarenal masses as the cause of adrenal gland destruction and the patient's symptoms. FDG PET-CT scan and histopathology confirmed the diagnosis of mature bilateral B-cell primary adrenal lymphomas. Though the patient showed an excellent initial response to the first four chemotherapy cycles, a relapse resulted in metastatic disease. This article highlights the PAL's disease course, imaging features, and management dilemma due to Chemotherapy's side effects and a higher recurrence rate. Keywords: Primary adrenal lymphoma, Primary adrenal insufficiency, R-CHOP, Role of imaging.

The Mediport Paradox: Mediastinitis and Pericardial Effusion With a Misplaced Mediport.

Totally implantable subcutaneous devices (TISDs) have become excellent options for patients requiring long-term chemotherapy, parenteral nutrition, and fluid replacement. As with all invasive devices and procedures, they come with their inherent risks, which may manifest immediately or at a later point in time. We present the case of a 74-year-old female with a history of hypertension, chronic obstructive pulmonary disease (COPD), ischemic stroke, breast cancer, and lung cancer who had mediport placement for chemotherapy administration. She received several infusions of pembrolizumab through her mediport and developed progressive dyspnea over four weeks. Upon evaluation at our institution, she was found to have a misplaced mediport with mediastinitis and pericardial effusion due to direct mediastinal exposure to immunotherapy. This case highlights the importance of systematic imaging review, regardless of suspected pathology, and encourages providers to have a low threshold to re-evaluate patients after device placement or immunotherapy commencement.

Emergent Hemodialysis Followed by Continuous Renal Replacement Therapy: A Management Challenge in a Patient With Life-Threatening Metabolic Acidosis of Multifactorial Etiology.

Metabolic acidosis is a frequently encountered laboratory finding in daily clinical practice. Rapid pH correction is almost always preferred and necessary while performing workup to identify the causative factors. We present the case of a 73-year-old male presenting with progressive dyspnea and severe metabolic acidosis. He had a pH of 6.6, bicarbonate of 1.8 mg/dL, lactic acid of 18.1 mg/dL, and pCO2 of 14.1 mmHg. The intensivist and nephrologist made a joint decision to rapidly correct the pH using bicarbonate and emergent hemodialysis. Subsequently, continuous renal replacement therapy (CRRT) was started, leading to a favorable outcome. Our patient's most likely etiology of lactic acidosis was metformin because he had a very high lactic acid, high anion gap metabolic acidosis, and acute renal failure on presentation. From our case and literature review, we suggest using hemodialysis, CRRT, and bicarbonate replacement for a better prognosis in patients with critical acidosis in view of frank renal failure and concurrent metformin use.

Sore Throat: Can It Be Primary Laryngeal Small Cell Carcinoma?

Small cell carcinoma of the larynx is a rare form of neuroendocrine carcinoma. Clinical and radiological properties are similar to other laryngeal cancers, prompting histopathology examination. Symptoms include sore throat, dysphagia, odynophagia, and weight loss. Multiple management options have been demonstrated in the literature. However, combined radiation and chemotherapy have proven to improve survival. Unfortunately, the prognosis for this cancer is dismal, as survival from diagnosis rarely exceeds two years. In this article, we present a 64-year-old female patient who presented with a sore throat and was diagnosed with primary small cell cancer of the larynx. Despite the relapse after the initial four cycles of chemotherapy with carboplatin and etoposide, our patient responded well to nivolumab and ipilimumab and is still in remission on a six-month follow-up.

Infectious Aortitis: Case Report and Literature Review.

Aortitis is the inflammation of the aorta secondary to either infectious or non-infectious etiologies. Infectious aortitis is a rare but potentially life-threatening condition. It is more common among older patients with preexisting pathology. Clinical presentation is variable, therefore, a high index of suspicion is required for timely diagnosis and management. We report a case of aortitis which was complicated with the development of a saccular abdominal aortic aneurysm. A 76-year-old male presented to the Emergency Department with two days of right lower quadrant abdominal pain. Clinical evaluation and imaging studies revealed abdominal aortitis, which progressed to a saccular abdominal aortic aneurysm. We highlight a unique presentation of infectious aortitis to raise awareness among physicians. We also reviewed the available literature on infectious aortitis to illustrate the importance of early diagnosis and appropriate treatment to improve the patients' outcomes.