Novel use of dynamic MR hydrography to rule out esophageal perforation post atrial fibrillation ablation in a patient with anaphylaxis to gadolinium.

Esophageal thermal injury is one of the most devastating complications of atrial radiofrequency ablation, and its diagnosis can be challenging. In this report, we highlight the novel use of free water as a contrast material to better visualize the esophageal lumen in a patient with anaphylaxis to Iodinated contrast media and Gadolinium who recently underwent atrial fibrillation ablation. This becomes particularly handy in patients with contrast allergy, and further emphasizes the role of multimodality imaging.

Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: A systematic review and meta-analysis of more than 66,000 subjects.

BACKGROUND: Worsening tricuspid regurgitation (TR) after either permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment. OBJECTIVE: This meta-analysis was designed to identify the overall incidence and patient-specific predictors of TR post-device implantation. METHODS: We searched electronic databases from inception to January 2023 for published studies that reported the incidence of TR worsening post-device implantation. The log odds ratio (OR) was used to summarize group differences. RESULTS: Our analysis included 29 studies with 66,590 participants. Patients who underwent device implantation (n = 1008) were significantly more likely to develop worsening TR than controls who did not undergo device implantation (n = 58,605) (OR 3.18; P < .01). In a total of 7777 patients, the pooled incidence of at least 1-grade worsening of TR post-device implantation was 24%. Worsening TR post-device implantation significantly increases mortality (hazard ratio 1.42; P = .02). Larger right atrial area (OR 1.11; P < .01) is significantly associated with an increased risk of worsening TR post-device implantation, while male patients are less likely to develop this complication than female patients (OR 0.74; P < .01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device implantation TR. Further, right ventricular dysfunction, pulmonary artery pressure, baseline mitral regurgitation, left ventricular ejection fraction, baseline atrial fibrillation, and age have no association with worsening TR post-device implantation. CONCLUSION: A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating more than 66,000 subjects, worsening TR significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.

Magnetic Resonance Features of a Recent Catheter Ablation of Left Posterior Fascicular Ventricular Tachycardia.

A 71-year-old male patient with a past medical history of hypertension, hyperlipidemia, and chronic kidney disease stage II presented with a complaint of intermittent palpitations for three months and was found to have wide complex tachycardia on the electrocardiogram (ECG). The patient was given adenosine and amiodarone, following which he underwent synchronized cardioversion at 150 Joules followed by 200 Joules without successful conversion. He was subsequently initiated on lidocaine drip at the rate of 1 to 4 mg/minute to maintain adequate rhythm control, which converted him to sinus rhythm and relieved his symptoms. An eventual assessment with an electrophysiology study identified the presence of incessant left ventricular tachycardia (VT). The mechanism was confirmed to be left posterior fascicular ventricular tachycardia (LPF-VT). Successful mapping and ablation for the LPF-VT were achieved. Post-procedure cardiac MRI showed two small areas of near-transmural delayed enhancement. These areas are associated with nulled areas in the inferolateral wall at the left posterior His-Purkinje fascicle. This case highlights fascicular VT as a separate clinical entity, with its characteristic ECG features and acute MRI features after ablation.

Persistent Cardiac Magnetic Resonance Imaging Features of Myocarditis Detected Months After COVID-19 Infection.

Acute myocarditis is commonly caused by viral infections resulting from viruses such as adenovirus, enteroviruses, and, rarely, coronavirus. It presents with nonspecific symptoms like chest pain, dyspnea, palpitation, or arrhythmias and can progress to dilated cardiomyopathy or heart failure. Fulminant myocarditis is a potentially life-threatening form of the condition and presents as acute, severe heart failure with cardiogenic shock. In this report, we discuss a case of a 41-year-old female who presented with cough and chest pain of two days' duration. The patient had a new-onset atrial flutter. Her chest auscultation revealed bilateral crackles. Laboratory workup revealed elevated troponin levels, and the patient tested positive for coronavirus disease 2019 (COVID-19) by nasopharyngeal swab polymerase chain reaction (PCR). Transthoracic echocardiogram revealed a low left ventricular (LV) ejection fraction of 35-40% compared to 55% one year prior, as well as a granular appearance of LV myocardium. The patient's condition subsequently improved clinically and she was discharged home. Due to cardiac involvement and characteristic myocardial appearance on the echocardiogram, cardiac magnetic resonance (CMR) imaging was performed for further evaluation about two months from the date of admission. CMR showed extensive myocardial inflammation with a typical pattern of sub-epicardial and mid-wall delayed enhancement, confirming the diagnosis of myocarditis. This case highlights myocarditis as a potential complication of COVID-19 that requires early diagnosis and proper management to improve patients' quality of life. Additionally, we highlight the features of myocarditis on CMR in the acute phase and two months after clinical recovery.

Spodick's Sign: A Case Report and Review of Literature.

Acute pericarditis is commonly diagnosed in patients who present with chest pain. Accurate diagnosis of acute pericarditis is essential because of its relative similarity to ST-elevation myocardial infarction (STEMI) in both clinical presentation and electrocardiogram (EKG) changes. Additionally, troponin elevation is occasionally seen in acute pericarditis due to myocardial involvement (myopericarditis), which makes accurate diagnosis more challenging. A 12-lead EKG remains the most useful diagnostic test in differentiating acute pericarditis from STEMI. Spodick's sign is a less recognized electrocardiographic feature of acute pericarditis and is frequently overlooked by clinicians. We present a case of a 52-year-old male who initially presented with acute onset substernal chest pain. His EKG revealed diffuse subtle ST elevation and downsloping TP segment (Spodick's sign). A coronary angiogram demonstrated normal coronaries which eliminated the possibility of coronary artery disease. In this article, we will discuss how to differentiate between acute pericarditis and myocardial infarction, with a focus on Spodick's sign, amongst other EKG findings suggestive of pericarditis.

Unusual Cause of Stroke.

Every year, more than 795,000 people in the United States have a stroke, the vast majority of which are ischemic. Cardiac myxoma is an unusual cause of stroke and accounts for less than 1% of ischemic strokes. We present a case of a 56-year-old male with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus, who presented with altered mental status, tinnitus, double vision, and diaphoresis. Due to concern for a cerebral vascular accident, a CT scan of the brain was obtained and showed no acute intracranial process. Brain MRI revealed multiple small acute infarcts involving bilateral posterior cerebral artery distribution. Further evaluation included transthoracic echocardiography that showed a large mobile mass in the left atrium measuring 3.5 x 2 cm intermittently projecting through the mitral valve. The patient underwent successful surgical resection of the left atrial mass. The pathology report confirmed the diagnosis of atrial myxoma. This case further highlights the importance of complete evaluation of stroke, including echocardiography, as well as the importance of careful surgical resection to prevent recurrence of systemic embolization and other complications of atrial myxoma.

Level and Prevalence of Spin in Published Cardiovascular Randomized Clinical Trial Reports With Statistically Nonsignificant Primary Outcomes: A Systematic Review.

Importance: Clinical researchers are obligated to present results objectively and accurately to ensure readers are not misled. In studies in which primary end points are not statistically significant, placing a spin, defined as the manipulation of language to potentially mislead readers from the likely truth of the results, can distract the reader and lead to misinterpretation and misapplication of the findings. Objective: To determine the level and prevalence of spin in published reports of cardiovascular randomized clinical trial (RCT) reports. Data Source: MEDLINE was searched from January 1, 2015, to December 31, 2017, using the Cochrane highly sensitive search strategy. Study Selection: Inclusion criteria were parallel-group RCTs published from January 1, 2015, to December 31, 2017 in 1 of 6 high-impact journals (New England Journal of Medicine, The Lancet, JAMA, European Heart Journal, Circulation, and Journal of the American College of Cardiology) with primary outcomes that were not statistically significant were included in the analysis. Data Extraction and Synthesis: Analysis began in August 2018. Data were extracted and verified by 2 independent investigators using a standard collection form. In cases of disagreement between the 2 investigators, a third investigators served as arbitrator. Main Outcomes and Measures: The classifications of spin type, severity, and extent were determined according to predefined criteria. Primary clinical outcomes were divided into safety of treatment, efficacy of treatment, and both. Results: Of 587 studies identified, 93 RCT reports (15.8%) met inclusion criteria. Spin was identified in 53 abstracts (57%; 95% CI, 47%-67%) and 62 main texts of published articles (67%; 95% CI, 57%-75%). Ten reports (11%; 95% CI, 6%-19%) had spin in the title, 35 reports (38%; 95% CI, 28%-48%) had spin in the results section, and 50 reports (54%; 95% CI, 44%-64%) had spin in the conclusions. Among the abstracts, spin was observed in 38 results sections (41%; 95% CI, 31%-51%) and 45 conclusions sections (48%; 95% CI, 38%-58%). Conclusions and Relevance: This study suggests that in reports of cardiovascular RCTs with statistically nonsignificant primary outcomes, investigators often manipulate the language of the report to detract from the neutral primary outcomes. To best apply evidence to patient care, consumers of cardiovascular research should be aware that peer review does not always preclude the use of misleading language in scientific articles.

Prasugrel vs. Ticagrelor for Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

BACKGROUND: The newer P2Y12 inhibitors have better efficacy than clopidogrel. However, whether ticagrelor or prasugrel have a better comparative safety and efficacy profile, especially in the long-term, remains inconclusive. OBJECTIVE: We compared prasugrel and ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). METHODS: MEDLINE and the Cochrane library were queried for randomized controlled trials (RCTs) or observational studies comparing prasugrel with ticagrelor in patients with ACS undergoing PCI. Random-effects pooling was used to calculate odds ratios (ORs) with 95% confidence intervals (CI). Analyses were stratified by duration of follow-up (short term [≤ 3 months] and long term [≥ 1 year]) and study design. RESULTS: In total, 14 studies (six RCTs, eight observational studies), including 40,188 patients, met eligibility criteria. Pooled analysis did not indicate that prasugrel significantly decreased all-cause mortality compared with ticagrelor in the short term (OR 0.49; 95% CI 0.20-1.20; p = 0.11) or long term (OR 0.74; 95% CI 0.48-1.15; p = 0.38). Pooled observational studies showed significantly lower long-term all-cause mortality (OR 0.63; 95% CI 0.43-0.92; p = 0.02) and short-term stent thrombosis (OR 0.46; 95% CI 0.28-0.75; p = 0.002) with prasugrel. No significant difference was observed in the risk of nonfatal myocardial infarction, ischemic stroke, bleeding, or repeat revascularization between the two groups. Results remained similar after stratification according to follow-up and study design. CONCLUSIONS: The present analysis suggests that prasugrel might have a better efficacy profile than ticagrelor in patients with ACS undergoing PCI. However, this advantage was only seen in pooled observational studies and is likely to be affected by selection bias.

Missing Vitamin C: A Case of Scorbutic Cardiac Tamponade.

Scurvy is a disorder of vitamin C deficiency which leads to vascular fragility and multisystemic complications. The paper presents a case of scurvy resulting in cardiac tamponade in addition to its classic manifestations. Life-threatening tamponade is an extreme presentation of scurvy and has not been reported in modern publications to the best of the present authors' knowledge. (Level of Difficulty: Beginner.).