All the king's men (and women): Fluoro-less leadless pacemaker implant in a severely obese patient.

INTRODUCTION: Severe obesity presents significant challenges in imaging and delivery of therapy, including pacemaker implant. METHODS AND RESULT: We present our experience implanting a leadless pacemaker (LP) in a severely obese man presenting with heart block. We describe our multidisciplinary approach using right internal jugular venous access and transesophageal imaging in lieu of fluoroscopy which failed to provide workable images in this instance. CONCLUSION: Ultrasound guided LP placement may have wider application in the midst of an ongoing obesity epidemic where fluoroscopy imaging is both limited and unsafe.

Immune Checkpoint Inhibitors and Cardiotoxicity: A Comparative Meta-Analysis of Observational Studies and Randomized Controlled Trials.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have uncommon associations with cardiotoxicity, yet these cardiotoxic effects are associated with high mortality. An accurate assessment of risk for cardiotoxicity is essential for clinical decision-making, but data from randomized controlled trials often differ from real-world observational studies. METHODS AND RESULTS: A systematic search of PubMed, Embase, Cochrane Library, and Scopus was performed, including phase II and III randomized controlled trials (RCTs) and observational studies (OSs) reporting myocarditis or pericardial disease, myocardial infarction, or stroke with an immunotherapy. Odds ratios (ORs) were used to pool results between ICIs and other cancer therapy in RCTs and OSs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. In total, 54 RCTs (N=38 264) and 24 OSs (N=12 561 455) were included. In RCTs, ICI use resulted in higher risk of myocarditis (OR, 3.55 [95% CI, 2.10-5.98]), pericardial disease (OR, 2.73 [95% CI, 1.57-4.77]), and myocardial infarction (OR, 1.83 [95% CI, 1.03-3.25]), compared with non-ICI (placebo or chemotherapy). In OSs, ICI use was not associated with myocarditis, pericardial disease, or myocardial infarction compared with controls; however, combination ICIs demonstrated higher risk of myocarditis compared with single ICI use (OR, 3.07 [95% CI, 1.28-7.39]). Stroke risk was not increased with use of ICIs in RCTs. CONCLUSIONS: We demonstrated increased risk of ICI myocarditis, pericardial disease, and myocardial infarction in RCTs but not OSs. Results of this study suggest there are differences between ICI cardiotoxicity risk, possibly suggesting differences in diagnoses and management, in clinical trials versus the OSs.

Impact of end stage renal disease on the clinical outcomes of diabetics admitted for heart failure: Analysis of national inpatient sample.

Introduction: Patients with diabetes and heart failure (HF) can have varying outcomes depending on whether they also have End Stage Renal Disease (ESRD). This study aimed to compare the outcomes of patients with diabetes and HF with and without ESRD. Methods: Data from the National Inpatient Sample (NIS) 2016-2018 was analyzed to find hospitalizations for patients with HF as the main diagnosis and diabetes as a secondary diagnosis, with and without ESRD. Multivariable logistic and linear regression analysis was used to adjust for confounding factors. Results: In the total cohort of 12215 patients with a principal diagnosis of heart failure and secondary diagnosis of type 2 diabetes, the in-hospital mortality rate was 2.5%. Patients with ESRD had higher odds of in-hospital mortality (1.37x) compared to those without ESRD. The mean difference in length of stay was higher for patients with ESRD (0.49 days) and in total hospital charges (13360 US$). Patients with ESRD had higher odds of developing acute pulmonary edema, cardiac arrest, and requiring endotracheal intubation. However, they had lower odds of developing cardiogenic shock or requiring an intra-aortic balloon pump insertion. Conclusion: The results suggest that ESRD leads to higher in-patient mortality, length of stay, and total hospital charges for patients with diabetes admitted for HF. The lower incidence of cardiogenic shock and intra-aortic balloon pump insertion in patients with ESRD may be due to timely dialysis.

When nerves fail: A cause of respiratory failure in a diabetic patient.

Background: Respiratory failure secondary to bilateral diabetic phrenic neuropathy is an uncommon clinical scenario. It is challenging to treat and often results in the need for long-term respiratory support. Case Presentation: We report a patient with long standing diabetes mellitus (DM) who presented with respiratory failure requiring mechanical ventilation. He was subsequently found to have reduced phrenic nerve and diaphragm compound action potential amplitude bilaterally on nerve conduction studies. Conclusion: Diabetic patients with unexplained shortness of breath should raise suspicion for diaphragmatic paresis from phrenic neuropathy.

The Novelty of Icosapent Ethyl in the Management of Hypertriglyceridemia and Alleviating Cardiovascular Risk.

Hypertriglyceridemia is believed to be independently associated with an elevated risk of cardiovascular disease (CVD) events. Lifestyle changes and dietary modifications are recommended for individuals with high serum triglyceride (TG) levels (150-499 mg/dl), and pharmacological therapy in addition to lifestyle modification is recommended when serum TG levels ≥ 500 mg/dl. A residual cardiovascular risk remains even in statin appropriate treated patients with CVD risk factors, and in this patient population, hypertriglyceridemia poses an independent and increased risk of ischemic events. In December 2019, the US FDA approved icosapent ethyl (IPE) as an adjunct to a maximally tolerated statin to reduce the risk of CVD events in adults with serum triglycerides > 150 mg/dl and have either established cardiovascular disease or diabetes and two or more additional CVD risk factors. Since IPE significantly decreases total ischemic events in the aforementioned patient population, it would be intriguing to know whether IPE alone added an advantage to lifestyle modification in the low-risk population, who has serum triglyceride between 150 mg/dl and 499 mg/dl.

Development of New-Onset or Progressive Atrial Fibrillation in Patients With Permanent HIS Bundle Pacing Versus Right Ventricular Pacing: Results From the RUSH HBP Registry.

Background Conventional right ventricular pacing (RVP) has been associated with an increased incidence of atrial fibrillation (AF). We sought to compare the occurrence of new-onset AF and assessed AF disease progression during long-term follow-up between His bundle pacing (HBP) and RVP. Methods and Results We included patients undergoing initial dual-chamber pacemaker implants at Rush University Medical Center between January 1, 2016, and June 30, 2019. A total of 360 patients were evaluated, and 225 patients (HBP, n=105; RVP, n=120) were included in the study. Among the 148 patients (HBP, n=72; RVP, n=76) with no history of AF, HBP demonstrated a lower risk of new-onset AF (adjusted hazard ratio [HR], 0.53; 95% CI, 0.28-0.99; P=0.046) compared with traditional RVP. This benefit was observed with His or RVP burden exceeding 20% (HR, 0.29; 95% CI, 0.13-0.64; P=0.002), ≥40% (HR, 0.31; P=0.007), ≥60% (HR, 0.35; P=0.015), and ≥80% (HR, 0.40; P=0.038). There was no difference with His or RV pacing burden <20% (HR, 0.613; 95% CI, 0.213-1.864; P=0.404). In patients with a prior history of AF, there was no difference in AF progression (P=0.715); however, in a subgroup of patients with a pacing burden ≥40%, HBP demonstrated a trend toward a lower risk of AF progression (HR, 0.19; 95% CI, 0.03-1.16; P=0.072). Conclusions HBP demonstrated a lower risk of new-onset AF compared with RVP, which was primarily observed at a higher pacing burden.

A Case of Asymptomatic Pulmonary Artery Aneurysm with Review of Management Strategies.

Pulmonary artery aneurysm (PAA) is defined as pulmonary artery diameter greater than 4 cm. With advances in cardiac imaging, the detection rate has increased but the natural history remains unknown. We present the case of a large, incidentally identified PAA in a patient with a history of congenital pulmonic stenosis.

Coronary Microvascular Dysfunction and the Role of Noninvasive Cardiovascular Imaging.

Patients with coronary microvascular dysfunction (CMD) have significantly higher rates of cardiovascular events, including hospitalization for heart failure, sudden cardiac death, and myocardial infarction (MI). In CMD, several pathophysiological changes lead to functional and structural abnormalities in the coronary microvasculature, which disrupt the ability of the vessels to vasodilate and augment myocardial blood flow in response to increased myocardial oxygen demand, causing ischemia and angina. With the advent of more advanced non-invasive cardiac imaging techniques, the coronary microvasculature has been subjected to more intense study in the past two decades-this has led to further insights into the diagnosis, pathophysiology, treatment, prognosis and follow-up of CMD. This review will highlight and compare the salient features of the currently available non-invasive imaging modalities used in these patients, and discuss the clinical utility of these techniques in the workup and management of these patients.

A Steady Cause of Unsteadiness: A Case of Thyroid-Associated Cerebellar Ataxia.

Encephalopathy with autoimmune thyroid disease (EAATD) is mostly associated with Hashimoto's thyroiditis and has been uncommonly reported with Grave's disease. This case is aimed to report the association of EAATD with thyroid peroxidase (TPO) and thyroid-stimulating immunoglobulin (TSI) antibodies in Grave's disease. We report a 55-year old male who presented with thyrotoxicosis and cerebellar ataxia and was diagnosed with Grave's disease based on clinical and biochemical findings. The patient was managed with anti-thyroid medications with resolution of both thyrotoxicosis and cerebellar symptoms proving the hypothesis that patient's encephalopathy was autoimmune and related to his thyroid disease. High index of suspicion should be maintained for EAATD in patients presenting with neurological deficits with associated clinical and biochemical evidence of autoimmune thyroid disease.

Rare Presentation of Cardiac Tamponade in a Patient With Subclinical Hypothyroidism.

Cardiovascular effects of hypothyroidism include bradycardia, diastolic hypertension, atrial fibrillation, prolonged QT interval leading to torsades de pointes, varying degrees of AV block, accelerated coronary artery disease, and pericardial effusion. Cardiac tamponade is rare in patients with hypothyroidism because of pericardial distensibility and slow accumulation of fluid. The amount and rate of accumulation of pericardial effusion are related to the severity of hypothyroidism. Though rare, significant pericardial effusion can be a manifestation of subclinical hypothyroidism.

A Curious Case of Coronary Vasospasm with Cardiogenic Shock: Type 1 Kounis Syndrome Complicated by Eosinophilic Myocarditis.

Kounis syndrome is a rare but life-threatening form of coronary vasospasm, defined by the co-occurrence of acute coronary syndrome and hypersensitivity reaction. We present a case of refractory coronary vasospasm with aborted sudden cardiac arrest secondary to type 1 Kounis syndrome, which was complicated by eosinophilic myocarditis and cardiogenic shock. A 29-year-old Hispanic woman with history of vasospastic angina, presented with recurrent episodes of angina at rest. Initial evaluation revealed hyper-eosinophilia, elevated troponin and diffuse ST segment depression on electrocardiogram (ECG). Suddenly, she developed bradycardia and had a sudden cardiac arrest. An urgent coronary angiogram after resuscitation revealed severe multifocal vasospasm which resolved following high doses of intracoronary vasodilators. Type 1 Kounis syndrome was suspected and she was initiated on intravenous corticosteroids and anti-histamines. Subsequently, she developed cardiogenic shock, and a cardiac magnetic resonance imaging (cMRI) showed diffuse subendocardial late gadolinium enhancement (LGE) suggestive of eosinophilic myocarditis. She was diagnosed with type 1 Kounis syndrome associated with eosinophilic myocarditis. Kounis syndrome should be suspected in patients with refractory vasospastic angina. When indicated, coronary angiography should be performed with administration of intracoronary vasodilators for diagnostic and therapeutic purposes. Although, definite diagnosis of eosinophilic myocarditis requires endomyocardial biopsy, cMRI can be a crucial non-invasive method for establishing the diagnosis.

Culprit Vessel Only Versus Multivessel Percutaneous Coronary Intervention in Acute Myocardial Infarction with Cardiogenic Shock: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous studies comparing outcomes between culprit vessel only percutaneous coronary intervention (CV-PCI) versus multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock in the setting of acute myocardial infarction have shown conflicting results. This meta-analysis investigates the optimal approach for management of these patients considering recently published data. METHODS: Electronic databases including MEDLINE, ClinicalTrials.gov and the Cochrane Library were searched for all clinical studies published until May 1, 2018, which compared outcomes in patients presenting with acute myocardial infarction and cardiogenic shock. Studies comparing CV-PCI versus MV-PCI in patients with multivessel coronary artery disease were screened for inclusion in final analysis. The primary end point was in-hospital/30 day mortality. Secondary endpoints included long term (>6 months) mortality, renal failure requiring renal replacement therapy, stroke, bleeding, and recurrent myocardial infarction. Odds ratio (OR) with 95% of confidence interval (CI) were computed and p values <0.05 were considered significant. RESULTS: Patient who underwent CV-PCI had significantly lower short-term mortality (in-hospital or 30-day mortality) (OR: 0.73, CI: 0.61-0.87, p = 0.0005), and lower odds of severe renal failure requiring renal replacement therapy (OR: 0.76, CI: 0.59-0.98, p = 0.03). There was no statistically significant difference in long-term mortality, stroke, bleeding, and recurrent myocardial infarction between two groups. CONCLUSION: This meta-analysis showed lower short-term mortality and decreased odds of renal failure requiring renal replacement therapy with CV-PCI compared to MV-PCI. However, subgroup analysis including studies exclusively assessing STEMI patients revealed no statistically significant difference in outcomes. Further randomized trials are needed to confirm these findings and evaluate long term results.

Women in Leadership Positions in Academic Cardiology: A Study of Program Directors and Division Chiefs.

BACKGROUND: Gender difference in the workplace continues to be a subject of great discussion. Cross-sectional studies demonstrate that women are often underrepresented in key leadership roles. We sought to examine the proportion of women in cardiology leadership positions and to compare the findings with the differences prevalent in the overall cardiology faculty. Furthermore, we aspired to compare the proportion of women in leadership positions to the proportion in which they entered the cardiology field. METHODS: This is a cross-sectional online study of Cardiology fellowship programs identified by American Medical Association's Fellowship and Residency Electronic Interactive Database (AMA FREIDA), conducted from March to April 2017. Data of all (n = 512) cardiology fellowship program directors as well as 69% (n = 140) cardiology division chiefs were collected. RESULTS: A lower percentage of women held the role of division chief (5% vs. 95%) and program director (14% vs. 86%). However, when compared to the proportion of women in the 1992 fellowship cohort, women were significantly overrepresented in the role of program directors, with no significant difference in representation at the level of division chief. When compared to the overall cardiology faculty, program directors had significantly more publications and were more likely to have an academic rank of full professor (40% vs. 28%) or associate professor (37% vs. 23%). Male program directors had a significantly higher number of research publications, H-index, and academic rank than their female counterparts; however, such difference was not seen at the level of division chief. CONCLUSIONS: Gender difference is present in both program director and division chief roles. However, when compared to the historical cohort, significant overrepresentation of women was seen in the program director position, while proportionate representation was seen in the division chief role.

Angioedema: A Life-threatening Complication of Tissue Plasminogen Activator.

Angioedema is a localized, non-pitting, non-dependent, submucosal, and subcutaneous swelling resulting from the extravasation of fluid into the interstitium due to the increased production of plasma kinins and histamine. It can present with urticaria or anaphylaxis and is usually associated with angiotensin-converting enzyme inhibitors (ACEis), complement deficiencies, or the side effects of tissue plasminogen activator (tPA). Orolingual angioedema following tPA for acute ischemic stroke is a transient, self-resolving hemifacial swelling contralateral to neurological deficits that can rarely progress to the airway, compromising it and leading to a life-threatening situation if not managed promptly.

Gram-Negative Pyomyositis in an Immunocompetent Patient.

Pyomyositis is an acute or sub-acute primary infection of the striated muscles. It is commonly misdiagnosed in its early stages due to its nonspecific presentation and lower suspicion among physicians when it comes to diagnosis. It has been historically associated with tropical climates but is being seen with increasing incidence in temperate regions. In both tropical and temperate areas, Staphylococcus aureus is the most common causative organism; gram-negative organisms are rare and traditionally only seen in immunocompromised patients. We report a case of Klebsiella pneumoniae pyomyositis in an immunocompetent patient with no risk factors. The awareness of the possibility of gram-negative pyomyositis in immunocompetent patients will broaden initial empiric antibiotic treatment, especially in those patients not responding to traditional empiric treatment.

Right Ventricle Perforation Post Pacemaker Insertion Complicated with Cardiac Tamponade.

Pacemaker-lead-associated right ventricular perforation is a life-threatening complication. Acute perforation usually presents within 24 hours. Patients with lead perforation are often asymptomatic but fatal complications like hemopericardium, leading to cardiac tamponade and death, are reported. Diagnosis is based on chest x-ray, computed tomography (CT) scan, and echocardiography. The management of the lead perforation is based on clinical presentation. Extraction is avoided in cases of chronic asymptomatic lead perforations because of the associated complications. Urgent intervention is needed in hemodynamically unstable patients with pericardial effusion or cardiac tamponade physiology.

Suppressed without a Cause: A Case of Idiopathic Immune Deficiency.

We report a case of a 45-year-old male who presented with a headache, fever, vomiting, somnolence, and difficulty walking for 10 days. His cerebrospinal fluid studies revealed cryptococcal meningitis. Chest and abdominal computed tomography (CT) scans showed splenomegaly along with mediastinal, retroperitoneal and inguinal lymphadenopathy. CD4 count turned out to be 208 µL-1. Human immunodeficiency virus (HIV) testing, serum protein electrophoresis, serum light chains and quantitative immunoglobulins were non-diagnostic and CD4 lymphopenia was attributed to acute infection. However, a persistent CD4 lymphopenia was seen in subsequent outpatient testing, which prompted a detailed workup for secondary causes of immunodeficiency. Repeated lymph node biopsies with analytic cytometric immunophenotypic analysis were normal, as was the bone marrow biopsy with detailed immunophenotypic and cytogenetic studies. The patient was hence being treated as a case of idiopathic CD4 lymphocytopenia.