Use of Virtual Reality and 3D Models in Contemporary Practice of Cardiology.

PURPOSE OF REVIEW: To provide an overview of the impact of virtual and augmented reality in contemporary cardiovascular medical practice. RECENT FINDINGS: The utilization of virtual and augmented reality has emerged as an innovative technique in various cardiovascular subspecialties, including interventional adult, pediatric, and adult congenital as well as structural heart disease and heart failure. In particular, electrophysiology has proven valuable for both diagnostic and therapeutic procedures. The incorporation of 3D reconstruction modeling has significantly enhanced our understanding of patient anatomy and morphology, thereby improving diagnostic accuracy and patient outcomes. The interactive modeling of cardiac structure and function within the virtual realm plays a pivotal role in comprehending complex congenital, structural, and coronary pathology. This, in turn, contributes to safer interventions and surgical procedures. Noteworthy applications include septal defect device closure, transcatheter valvular interventions, and left atrial occlusion device implantation. The implementation of virtual reality has been shown to yield cost savings in healthcare, reduce procedure time, minimize radiation exposure, lower intravenous contrast usage, and decrease the extent of anesthesia required. These benefits collectively result in a more efficient and effective approach to patient care.

A Female in Her 50s With Caseating Mitral Annulus Calcification.

This case report describes a diagnosis of caseating mitral annulus calcification in a female patient with a history of peritoneal dialysis who presented with confusion and disorientation.

Prevalence of valvular heart disease in cardiac amyloidosis and impact on survival.

BACKGROUND: Limited data exists on the prognostic impact of valvular heart disease in cardiac amyloidosis (CA). We therefore sought to define the prevalence of valvular disease in patients with CA and assess the effects of significant valve disease on survival. METHODS: This multi-center retrospective cohort study included consecutive patients with confirmed transthyretin (TTR) or light chain (AL) amyloidosis. Echocardiographic data closest to the date of amyloid diagnosis was reviewed, and severity was graded according to ASE guidelines. Kaplan-Meier survival analysis was performed to compare survival between patients with moderate or greater valve disease against those with mild or less disease. RESULTS: We included 345 patients (median age 76 years; 73 % men; 110 AL, 235TTR). The median survival for the total patient cohort with cardiac amyloidosis was 2.92 years, with 30 % of patients surviving at five years after their diagnosis. Median survival comparing AL vs ATTR was 2.58 years vs 2.82 years (p = 0.67) The most common valvular abnormalities in the total cohort were mitral (62 %) and tricuspid (66 %).regurgitation There was a statistically significant difference in median survival between patients with no or mild MR compared to those with moderate or severe MR (2.92 years vs 3.35 years, p = 0.0047) (Fig. 5). There was a statistically significant difference in median survival in patients with no or mild TR compared to those with moderate or severe TR (3.35 years vs 2.3 years, p = 0.015). CONCLUSION: Our study demonstrates a significant prevalence of mitral and tricuspid regurgitation in CA, with patients with moderate to severe MR and TR having a poorer prognosis.

Concomitant treatment of sustained ventricular tachycardia and hypertrophic cardiomyopathy with transcoronary ethanol ablation: a case report.

Background: The recommended treatment for recurrent ventricular tachycardia in patients with hypertrophic cardiomyopathy that is not amenable to defibrillator implantation due to shock burden is radiofrequency ablation. In patients with deeply intramural foci of ventricular tachycardia, traditional unipolar ablation has a lower probability of success. Case summary: A 66-year-old Caucasian man was admitted with ventricular tachycardia, which recurred despite antiarrhythmic drugs. On cardiac magnetic resonance imaging, he was discovered to have septal hypertrophic cardiomyopathy, which was not significant on echocardiogram. The focus of ventricular tachycardia was suspected to be buried deeply within the hypertrophic segment as localized by late gadolinium enhancement. The patient underwent transcoronary ethanol ablation, which abated the ventricular tachycardia while also completely decreasing his invasively measured left ventricular outflow tract obstruction gradient from 45 to 17 mmHg. Discussion: Transcoronary ethanol ablation may be successfully applied to simultaneously treat ventricular arrhythmia superimposed within a segment of hypertrophic cardiomyopathy. Further data are needed to evaluate long-term success of this strategy vs. traditional radiofrequency ablation.

The value of ultrasound enhancing agents in the echocardiographic acquisition of pulmonary artery systolic pressure: An invasive to non-invasive correlation study.

PURPOSE: Right heart catheterization (RHC) is the gold standard for the assessment of pulmonary artery systolic pressures (PASP). Despite high utilization of echocardiography for the non-invasive assessment of PASP, the data comparing real-time non-invasive echocardiographic PASP with invasive PASP is limited. Furthermore, evidence regarding the utility and diagnostic accuracy of ultrasound enhancing agents (UEA) for non-invasive PASP assessment is lacking. To evaluate the accuracy of non-invasive PASP assessment with real-time invasive measures and the incremental benefit of UEA in this setting. METHODS: This was a prospective cohort study of 90 patients, undergoing clinically indicated RHC for hemodynamic assessment. All patients underwent a limited echocardiogram during RHC. Tricuspid regurgitant velocity (TRV) was measured on unenhanced echo, in the setting of centrally administrated agitated saline, then as either centrally administered or peripherally administered UEA. RESULTS: Of the 90 patients enrolled in our study, 41% had pulmonary hypertension. The overall mean PASP measured by RHC was 32.8 mmHg (+/- 11.3 mmHg). Unenhanced echocardiograms had a moderate correlation with invasive PASP (r = 0.57; p = < 0.001) which improved to a strong correlation with administration of agitated saline (r = 0.75; p = < 0.001) or centrally administered UEA (r = 0.77; p = < 0.001), with the best correlation noted with peripherally administered UEA (r = 0.83; p = < 0.001). Against invasive PASP, agitated saline enhanced PASP had the lowest bias (0.12mmHg; -15.6 to 15.8mmHg) when compared with all other non-invasive measures of PASP. CONCLUSIONS: Unenhanced echocardiographic estimation of TRV was found to have a poorer correlation with invasively measured PASP when compared to agitated saline and centrally administered UEA. Agitated saline enhanced PASP demonstrated the lowest bias with invasive PASP when compared to other non-invasive measures of PASP.

Personalized Postacute Hospitalization Recovery: A Novel Intervention to Improve Patient Experience and Reduce Cost.

GOAL: Readmissions are a significant financial burden for payers. Cardiovascular-related discharges are particularly prone to readmission. Posthospital discharge support can impact patient recovery and probably reduce patient readmissions. This study aimed to address the underlying behavioral and psychosocial factors that can negatively affect patients after discharge. METHODS: The study population was adult patients admitted to the hospital with a cardiovascular diagnosis who had a plan to discharge home. Those who consented to participate were randomized to intervention or control groups on a 1:1 basis. The intervention group received behavioral and emotional support, whereas the control group received usual care. Interventions included motivational interviewing, patient activation, empathetic communication, addressing mental health and substance use, and mindfulness. PRINCIPAL FINDINGS: Observed total readmission costs were significantly lower in the intervention group than in the control group ($1.1 million vs. $2.0 million) as was the observed mean cost per readmitted patient ($44,052 vs. $91,278). The mean expected cost of readmission after adjustment for confounding variables was lower in the intervention group than in the control group ($8,094 vs. $9,882, p = .011). PRACTICAL APPLICATIONS: Readmissions are a costly spend category. In this study, posthospital discharge support addressing the psychosocial factors contributing to patients' readmissions resulted in a lower total cost of care for those with a cardiovascular diagnosis. We describe an intervention that is reproducible and can be scaled broadly through technology to reduce readmission costs.

A case series of desmoplakin cardiomyopathy: a mimic of viral myocarditis.

Background: Clinical features and imaging presentation of myocarditis can overlap with other inflammatory or arrhythmogenic cardiomyopathies. Desmoplakin (DSP) is an important structural cardiac protein. Mutations in the DSP gene are associated with a variant of arrhythmogenic right ventricular cardiomyopathy (ARVC). Interestingly, this distinct genetic cardiomyopathy can also present with a myocardial inflammation and fibrosis pattern that may mimic other forms of myocarditis including viral myocarditis, which can raise a clinical challenge. We report two cases of DSP cardiomyopathy, which were initially thought to represent coronavirus disease of 2019 (COVID-19) myocarditis. Case summary: First patient is a 21-your-old woman with no past medical history but family history of presumed 'viral myocarditis' and ventricular tachycardia in her brother. She presented with acute chest pain and elevated cardiac enzymes. She tested positive for COVID-19 and given the suspicion for possible COVID-19 related acute myocarditis, cardiac magnetic resonance imaging obtained and revealed regional wall motion abnormalities, several areas of subepicardial and pericardial late gadolinium enhancement (LGE). Ambulatory cardiac monitoring showed runs of non-sustained ventricular tachycardia and considering her family history of arrhythmogenic myocarditis, genetic testing was performed that was positive for a likely pathogenic heterozygous mutation of DSP gene. She declined the recommended implantable cardioverter defibrillator (ICD).Second patient is a 34-year-old physician with no significant past medical history who works at a COVID-19 unit and presented with syncope and was found to have ventricular tachycardia. Echocardiogram revealed severely dilated left ventricle and globally depressed systolic function with left ventricular ejection fraction of 20%. Coronary computed tomography angiography showed no evidence of coronary atherosclerosis. Cardiac magnetic resonance imaging revealed several areas of mid myocardial and pericardial LGE. Subcutaneous ICD was implanted and an endomyocardial biopsy had evidence of lymphocytic myocarditis and adipose tissue infiltration of the myocardium. Genetic testing revealed pathogenic heterozygous DSP mutation. He underwent epicardial ablation for the episodes of ventricular tachycardia despite medical therapy. He was able to return to work and has not had any further episodes of arrhythmia. Conclusion: Mutations in the DSP gene are associated with left dominant arrhythmogenic cardiomyopathy, which is a variant of ARVC. Beside left ventricular systolic dysfunction and ventricular tachyarrhythmias, carriers of these mutations may present with episodes of chest pain associated with elevated cardiac enzymes and cardiac imaging findings indistinguishable from other forms of acute myocarditis including viral myocarditis. Currently, there are no guidelines for diagnosis and treatment of this entity.

Impact of Tafamidis on Survival in a Real-World Community-Based Cohort.

Tafamidis is the only therapy shown to improve survival in transthyretin cardiac amyloidosis (ATTR) based on randomized controlled trial data. We sought to evaluate the impact of tafamidis on survival in a real-world community-based cohort. This was a prospective observational cohort study that included consecutive patients with confirmed ATTR based on biopsy or TcPYP imaging. Baseline characteristics were compared between patients taking tafamidis vs not, and Kaplan-Meier survival analysis was performed to compare survival between these groups. We examined the reasons that ATTR patients were not on tafamidis. Of 107 ATTR patients, median age was 83.9 years, 79% were men, and 63 (59%) of them were on tafamidis. Demographics and baseline cardiovascular risk factors did not differ significantly between those on vs off tafamidis, although there was a higher proportion of NYHA Class III or IV heart failure in those off tafamidis (76% vs 57%, P < 0.01). The most common reasons patients were not on tafamidis included delays in obtaining the drug or financial barriers (59%) and NYHA Class IV heart failure (19.5%). Patients taking tafamidis had a significantly higher median survival compared to those not on tafamidis (median survival 6.70 vs 1.43 years, P < 0.0001). Our study demonstrates significantly improved survival in ATTR patients taking tafamidis. Barriers exist to tafamidis initiation including delayed access and affordability, and efforts should be made to improve patient access.

Prognostic Value of Venous Thromboembolism Risk Assessment Models in Patients with Severe COVID-19.

Introduction Severe novel corona virus disease 2019 (COVID-19) causes dysregulation of the coagulation system with arterial and venous thromboembolism (VTE). We hypothesize that validated VTE risk scores would have prognostic ability in this population. Methods Retrospective observational cohort with severe COVID-19 performed in NorthShore University Health System. Patients were >18 years of age and met criteria for inpatient or intensive care unit (ICU) care. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) and Caprini scores were calculated and patients were stratified. Results This study includes 184 patients, mostly men (63.6%), Caucasian (54.3%), 63 years old (interquartile range [IQR]: 24-101), and 57.1% of them required ICU care. Twenty-seven (14.7%) thrombotic events occurred: 12 (6.5%) cases of disseminated intravascular coagulation (DIC), 9 (4.9%) of pulmonary embolism, 5 (2.7%) of deep vein thrombosis, and 1 (0.5%) stroke. Among them, 86 patients (46.7%) died, 95 (51.6%) were discharged, and 3 (1.6%) were still hospitalized. "Moderate risk for VTE" and "High risk for VTE" by IMPROVE score had significant mortality association: (hazard ratio [HR]: 5.68; 95% confidence interval [CI]: 2.93-11.03; p < 0.001) and (HR = 6.22; 95% CI: 3.04-12.71; p < 0.001), respectively, with 87% sensitivity and 63% specificity (area under the curve [AUC] = 0.752, p < 0.001). "High Risk for VTE" by Caprini score had significant mortality association (HR = 17.6; 95% CI: 5.56-55.96; p < 0.001) with 96% sensitivity and 55% specificity (AUC = 0.843, p < 0.001). Both scores were associated with thrombotic events when classified as "High risk for VTE" by IMPROVE (HR = 6.50; 95% CI: 2.72-15.53; p < 0.001) and Caprini scores (HR = 11.507; 95% CI: 2.697-49.104; p = 0.001). Conclusion The IMPROVE and Caprini risk scores were independent predictors of mortality and thrombotic events in severe COVID-19. With larger validation, this can be useful prognostic information.

Drive-Through Model for Anticoagulation Clinics During the COVID-19 Pandemic.

The coronavirus disease of 2019 (COVID-19) has posed a major challenge for providers and patients. A large number of patients with atrial fibrillation, venous thromboembolism, or valvular heart disease are chronically anticoagulated with vitamin K antagonists and rely on frequent follow ups at anticoagulation clinics for management of their anticoagulation therapy. The need for isolation during COVID-19 pandemic can potentially limit access to health care including anticoagulation clinics and directly affect the care of patients on chronic anticoagulation. Therefore, we created a drive-through clinic to bridge the gap of continuation of care and preservation of social distancing precautions. In this manuscript, we report the steps in implementing such initiative which can be applied to other clinics during a pandemic.

The Novel Coronavirus Disease (COVID-19) and Its Impact on Cardiovascular Disease.

The coronavirus disease 2019 (COVID-19) pandemic has placed a significant strain on healthcare providers. As the number of patients continue to surge, healthcare workers are now forced to find different approaches to practicing medicine that may affect patient care. In addition, COVID-19 has many cardiovascular complications that affect the clinical course of patients. In this article, we summarize the cardiovascular impact of COVID-19 and some of the challenges that patients and the healthcare system will face during this pandemic.