Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes.

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p = 0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90 days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

Assessing the future risks of subsequent pregnancies in peripartum cardiomyopathy.

Peripartum cardiomyopathy is a myocardial disease process which occurs in young women either in late pregnancy or the early postpartum period. Due to the young age of women effected by this disease, many of these patients elect to pursue a subsequent pregnancy after their initial diagnosis. Currently, echocardiography is used to better elucidate the cardiovascular risks these young patients face when undergoing a subsequent pregnancy; however, the most accurate modality to determine these risks is debatable. In this review, we explore the current literature regarding the use and accuracy of resting transthoracic echocardiography, exercise stress echocardiography, and dobutamine stress echocardiography in risk stratification of a subsequent pregnancy in a patient with peripartum cardiomyopathy.

Impact of COVID-19 on Heart Failure Hospitalizations.

The Novel Coronavirus Disease 2019 (COVID-19) pandemic has transformed individual lives and societal framework on a global scale, and in no other sector is this more evident than healthcare. Herein, we aim to describe the impact of the current COVID-19 pandemic and its associated restrictions on heart failure (HF) admissions. In this retrospective cohort study, we obtained administrative data for patients with a primary discharge diagnosis of HF (identified by ICD-10 code) with discharge dates ranging from January 2019 to November 2020. The study is comprised of 2 distinct sub-cohorts: HF admissions during the COVID-19 pandemic (case) period from March 2020 to October 2020 and corresponding control period during the previous year (March 2019 to December 2019). Primary outcome analysis involved comparison of total and daily HF admissions and secondary outcomes included hospital Length of Stay (LOS) and 30-day readmissions. The number of total HF admissions and average daily admissions were significantly lower in 2020 compared to 2019 (774 vs. 864; p < 0.001 and 3.17 vs. 3.53 days; p < 0.001), respectively. Average length of stay was significantly higher between March and October 2020 relative to the same months in 2019 (6.05 vs. 5.25 days; p < 0.001). Thirty-day readmission rates were also significantly higher in March-October 2020 compared to the same months in 2019 (20.6% vs. 19.1%; p < 0.001). During the pandemic, both readmission rates and length of stay for HF-related admissions were significantly impacted. The COVID-19 pandemic significantly impacted HF-related admissions as well as associated LOS and 30-day readmissions. High-risk patients should be identified carefully, and timely and appropriate treatment should be provided.

Predictors of reduced cardiac index in patients with acute submassive pulmonary embolism.

OBJECTIVES: Determine the baseline clinical, laboratory, and echocardiographic values that predict reduced cardiac index (CI) among subjects with acute submassive pulmonary embolism (PE). BACKGROUND: Submassive PE represents a large portion of acute PE population and there is controversy regarding optimal treatment strategies for these patients. There is significant heterogeneity within the submassive PE population and further refinement of risk stratification may aid clinical decision-making. METHODS: We identified subjects with normotensive acute PE who underwent echocardiogram and right heart catheterization (RHC) prior to catheter-directed thrombolysis (CDT). We sought to determine the predictors of reduced CI, defined as CI < 2.2 L min-1 m-2 . RESULTS: Thirty-two subjects met the inclusion criteria and 41% had reduced CI. Baseline variables did not distinguish subjects with reduced versus normal CI. Brain natriuretic peptide (BNP) was significantly different between the reduced versus normal CI groups (BNP 440 vs. 160 pg/ml, p = .004, respectively). Univariate logistic regression identified BNP, right ventricular (RV):left ventricular (LV) diameter ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular systolic pressure as predictors of reduced CI. In a multivariate logistic regression model, only TAPSE was an independent predictor of reduced CI. ROC curve analysis identified the following optimal cut points for prediction of reduced CI: BNP > 216 pg/ml, RV:LV ratio > 1.41, or TAPSE <1.6 cm. CONCLUSIONS: Almost half of subjects with acute submassive PE have reduced CI, despite normal systemic blood pressure. Optimal cut points for BNP, RV:LV ratio, and TAPSE were identified to predict reduced CI among patients with acute PE. These findings may aid in clinical decision-making and risk stratification of patients with acute submassive PE.

Prognostic Value of Computed Tomography Versus Echocardiography Derived Right to Left Ventricular Diameter Ratio in Acute Pulmonary Embolism.

BACKGROUND: Computed Tomography (CT) Pulmonary Angiography is the most commonly used diagnostic study for acute pulmonary embolism (PE). Echocardiogram (ECHO) is also used for risk stratification in acute PE, however the diagnostic performance of CT versus ECHO for risk stratification remains unclear. METHODS: CT and ECHO right ventricle (RV) and left ventricle (LV) diameters were measured in a retrospective cohort of patients with acute PE. RV:LV diameter ratios were calculated and correlation between CT and ECHO RV:LV ratio was assessed. Sensitivity and specificity for the composite adverse events endpoint of mortality, respiratory failure requiring intubation, cardiac arrest, or shock requiring vasopressors within 30 days of admission were assessed for CT or ECHO derived RV:LV ratio alone and in combination with biomarkers (troponin or B-type natriuretic peptide). RESULTS: A total of 74 subjects met the inclusion criteria and had a mean age of 62±18 years. The proportion of patients with RV:LV >1 was similar when comparing CT (37.8%) versus ECHO (33.8%) (P = 0.61). A statistically significant correlation was found between CT derived and ECHO derived RV:LV diameter ratio (r = 0.832, P < 0.001). The sensitivity and specificity to predict 30-day composite adverse events for CT versus ECHO derived RV:LV diameter ratio >1 together with positive biomarker status was similar with sensitivity and specificity of 87% and 41% versus 87% and 42%, respectively. CONCLUSIONS: In patients with acute PE, CT and ECHO RV:LV diameter ratio correlate well and identify similar proportion of PE patients at risk for early adverse events. These findings may streamline risk stratification of patients with acute PE.

Bupropion in the treatment of postural orthostatic tachycardia syndrome (POTS): a single-center experience.

Postural orthostatic tachycardia syndrome (POTS) is estimated to impact millions of people each year. However, there is no established gold standard for its treatment. Bupropion is a norepinephrine and a dopamine reuptake inhibitor and has been implicated as a potential treatment for POTS. We performed a non-randomized retrospective chart review on 47 patients with POTS with statistical analysis evaluating for significant findings including reduced orthostasis and improvement of symptoms with the use of bupropion. Bupropion was not associated with a statistically significant improvement in orthostatic vitals but there was an overall reduction in reported syncope. While the use of bupropion does not show a statistically significant impact on orthostatic vitals in patients with POTS, it did show a degree of improvement in syncope and as such might be useful in patients with syncope-predominant POTS.

Long-term mortality after massive, submassive, and low-risk pulmonary embolism.

Guidelines for management of normotensive patients with acute pulmonary embolism (PE) emphasize further risk stratification on the basis of right ventricular (RV) size and biomarkers of RV injury or strain; however, the prognostic importance of these factors on long-term mortality is not known. We performed a retrospective cohort study of subjects diagnosed with acute PE from 2010 to 2015 at a tertiary care academic medical center. The severity of initial PE presentation was categorized into three groups: massive, submassive, and low-risk PE. The primary endpoint of all-cause mortality was ascertained using the Centers for Disease Control National Death Index (CDC NDI). A total of 183 subjects were studied and their median follow-up was 4.1 years. The median age was 65 years. The 30-day mortality rate was 7.7% and the overall mortality rate through the end of follow-up was 40.4%. The overall mortality rates for massive, submassive, and low-risk PE were 71.4%, 44.5%, and 28.1%, respectively (p < 0.001). Landmark analysis using a 30-day cutpoint demonstrated that subjects presenting with submassive PE compared with low-risk PE had increased mortality during both the short- and the long-term periods. The most frequent causes of death were malignancy, cardiac disease, respiratory disease, and PE. Independent predictors of all-cause mortality were cancer at baseline, age, white blood cell count, diabetes mellitus, liver disease, female sex, and initial presentation with massive PE. In conclusion, the diagnosis of acute PE was associated with substantial long-term mortality. The severity of initial PE presentation was associated with both short- and long-term mortality.

Cannabis Smoking-induced Diffuse Alveolar Hemorrhage.

Cannabis smoking is common among adolescents and young adults. Diffuse alveolar hemorrhage (DAH) is a rare and life-threatening complication of cannabis abuse. DAH is characterized by bleeding into alveoli secondary to the disruption of the alveolar-capillary basement membrane as a result of an injury at the level of alveolar microcirculation. The differential diagnosis of DAH includes systemic vasculitis, bland pulmonary hemorrhage, and alveolar damage. The impact of cannabis on the respiratory function includes mucus hypersecretion, inflammatory edema, and increased alveolar permeability. Moreover, in vitro coagulation studies on rats showed that two major cannabinoids, cannabinol and THC, have antithrombotic activity. We present two cases of cannabis use resulting in acute lung injury and diffuse alveolar hemorrhage.

Analysis of Triphenylmethane Dye Residues and their Leuco-Forms in Frozen Fish by LC-MS/MS, Fish Microbial Quality, and Effect of Immersion in Whole Milk on Dye Removal.

A rapid and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was validated and used to quantify crystal violet (CV), leucocrystal violet (LCV), malachite green (MG), leucomalachite green (LMG), and brilliant green (BG) residues in frozen fish (121 samples) from various countries, in order to detect the use of prohibited antibiotic dyes in fish for human consumption. The microbial quality of the fish was also assessed along with the effectiveness of a simple treatment with whole fat milk to reduce the levels of CV and LCV contamination. CV and LCV were the only two residues detected. They were found in farmed Pangasius (0.362 to 41.34 µg/kg and 0.178 to 10.58 µg/kg, respectively) and Tilapia (1.24 to 9.48 µg/kg and 1.29 to 2.81 µg/kg). Based on aerobic plate count (APC), 74%, 59%, and 55% of the samples of Tilapia fillets (from China) and Pangasius fillets (United Arab Emirates and Vietnam), and 100% and 50% of the skin samples of Hake (Argentina and U.S.A.) were of unacceptable microbial quality (APC > 107 cfu/g). Human pathogens, namely Escherichia coli, Staphylococcus aureus, and Vibrio spp., were detected in most fish. A significant reduction in CV and LCV concentrations by more than a third was achieved after immersing Pangasius and Tilapia fillets in whole fat milk for 120 minutes. These findings support the necessity of regular inspections and monitoring of CV and other antibiotic dye residues in fish, along with routine assessments of fish microbial quality, in order to protect public health. PRACTICAL APPLICATION: The described LC-MS/MS method can be used to rapidly and simultaneously quantify antibiotic dye residues in frozen fish. CV and LCV were detected in farmed Pangasius and Tilapia fillets and their concentrations was reduced by more than one third after immersing the fillets in whole milk for 120 min, a treatment which is not intended to replace safe fish farming practices upstream to artificially lower the level of banned dyes in fish. The findings support the necessity of regular inspections and monitoring of CV and other antibiotic dye residues in fish, along with assessments of fish microbial quality, to protect public health.

Posttransplant Tacrolimus-Induced Diabetic Ketoacidosis: Review of the Literature.

Diabetic ketoacidosis (DKA) in patients receiving tacrolimus as part of their immunosuppressive regimen is a rarely reported adverse event. We report a patient with autosomal dominant polycystic kidney disease (ADPKD) and no known history of diabetes mellitus who presented with DKA, 3 months after kidney transplantation.

Safety and Efficacy of Leadless Pacemakers: A New Era of Pacing.

Leadless pacemakers are evolving as a new technologic alternative to conventional transvenous pacemakers, though potential short-term and long-term complications have been recognized. The two currently available right ventricular leadless pacing systems are the Nanostim™ Leadless Cardiac Pacemaker (Abbott Laboratories, Chicago, IL, USA) and the Micra™ Transcatheter Pacing System (Medtronic, Minneapolis, MN, USA). This review aims to highlight the safety and efficacy of leadless pacemakers using these two devices as exemplars.

Patient Factors But Not the Use of Novel Anticoagulants or Warfarin Are Associated With Internal Jugular Vein Access-Site Hematoma After Right Heart Catheterization.

INTRODUCTION: Right heart catheterization (RHC) is routinely performed to assess hemodynamics. Generally, anticoagulants are held prior to the procedure. At our center, anticoagulants are continued and ultrasound guidance is always used for internal jugular vein access. A micropuncture access kit is used to place a 5 or 6 Fr sheath using the modified Seldinger technique. Manual compression is applied for 10-15 min and the patient is observed for at least 2 hours after the procedure. In a retrospective analysis, we investigated the risk of bleeding complications associated with RHC via the internal jugular vein in patients with and without full anticoagulation. METHODS AND RESULTS: Our catheterization laboratory database was searched for adult patients who underwent RHC by a single operator between January 2012 and December 2015. A total of 571 patients were included in the analysis. Baseline characteristics, labs, relevant invasive hemodynamics, co-morbid conditions, and incidence of access-site hematoma are presented. Multivariable binary logistic regression was performed using IBM SPSS v. 23.0 software. Statistically significant associations with access-site hematoma were observed with body mass index (P=.02; 95% confidence interval [CI], 1.0-1.1), right atrial pressure (P=.03; 95% CI, 0.7-0.9), and dialysis dependence (P<.01; 95% CI, 0.1-0.6). There was no association of access-site hematoma with the use of anticoagulants (P>.99). CONCLUSION: The incidence of internal jugular vein access-site hematoma is small when using careful access techniques for RHC even with the continued use of novel oral anticoagulants and warfarin. Patient characteristics and co-morbid conditions are related to bleeding complications.

Role of closed loop stimulation pacing (CLS) in vasovagal syncope.

Vasovagal syncope (VVS) or neurocardiogenic syncope is defined by transient loss of consciousness with spontaneous and rapid recovery. Recently, a closed loop stimulation (CLS) pacing system has emerged as a new strategy which appears superior to conventional pacing for patients with refractory syncope. However, its efficacy remains of considerable debate and large randomized controlled clinical trials are needed. Between 2002 and 2017, 12 total studies evaluated the use of CLS pacing in patients with refractory VVS, and are summarized in this article.

Alveolar Soft Part Sarcoma with Unusual Cardiac Metastasis: A Case Report and Review of the Literature.

Alveolar soft part sarcoma is a very uncommon soft tissue malignancy which accounts for <1% of soft tissue sarcoma. It is a malignant and highly vascular tumor arising most commonly in the musculature of the lower extremities, with metastasis primarily to the lungs, bones, and brain. Cardiac metastasis is very rare and only 5 cases have been reported in the literature so far. We report a case of a young woman with a history of surgically resected alveolar soft part sarcoma of left thigh who presented with persistent dry cough and was found to have a cardiac mass, which on biopsy proved to be alveolar soft part sarcoma.

Ivabradine in the treatment of postural tachycardia syndrome (POTS), a single center experience.

BACKGROUND: Ivabradine is a selective If  channel blocker that reduces heart rate without affecting other cardiovascular functions. In case reports and case series, it was shown to improve symptoms in patients with postural tachycardia syndrome (POTS). METHODOLOGY AND RESULTS: This retrospective study examined patients who were diagnosed with POTS and received ivabradine as part of their treatment. Forty-nine patients (47 females, 95.9%) received ivabradine. The average age was 35.1 ± 10.35 years. The most common symptoms were palpitations and lightheadedness and both improved significantly, 88.4% and 76.1% response rate, respectively. A total of 38 patients reported improvement in their symptoms. In addition, ivabradine resulted in an objective decrease in sitting and standing heart rate (78.1 ± 10.7 vs 72.5 ± 7.6, P-value: 0.01) and (107.4 ± 14.1 vs 95.1 ± 13.7, P-value: < 0.001), respectively, with no significant change in blood pressure. The most common reported side effect was luminous phenomena/visual brightness occurring in nine patients. However, none of the patients stopped ivabradine due to side effects. CONCLUSION: Our study shows that ivabradine is likely to be effective in treating patients with POTS. Nearly 78% of our cohort reported a significant improvement in symptoms with no major adverse effects reported. A future randomized, placebo-controlled trial is warranted.

Diagnosis and management of primary effusion lymphoma in the immunocompetent and immunocompromised hosts.

Primary effusion lymphoma (PEL) is an uncommon non-Hodgkin lymphoma associated with human herpes virus-8 (HHV-8) that grows mainly in serous body cavities. The most common presentation of PEL is that of a young immunocompromised male with shortness of breath, as the pleural cavity is most commonly affected. Diagnosis is primarily based on fluid cytology in which PEL cells display variable morphology and a null lymphocyte immunophenotype; however, evidence of HHV-8 infection within the neoplastic cell is essential. Patients have commonly been treated with systemic multidrug chemotherapy and antiretroviral therapy if they were HIV positive or were immunocompromised for other reasons. In the immunocompetent patient, there have been no agreed-upon pathways for management of this condition. Progression of disease is common and median survival is approximately 6 months. Novel intrapleural treatments with antiviral agents such as intracavity cidofovir have shown to be effective in controlling local disease, and ongoing clinical trials may provide some promise in the treatment for this condition.