Role of echocardiography in patients treated with immune checkpoints inhibitors.

Immune-related adverse events occurring in the heart (cardiac immune-related adverse events; irAEs) by immune checkpoint inhibitors (ICIs) include myocarditis, arrhythmia, conduction disturbance, pericardial diseases, and takotsubo cardiomyopathy. Cardiac irAEs are rare but life-threatening. In cardio-oncology, the study of cardiac disorders caused by cancer treatment has recently attracted attention, and such studies may elucidate the pathophysiology of cardiac irAEs and contribute to management strategies. This review discusses the pathogenic mechanisms underlying cardiac irAEs and the role of echocardiography in patients treated with ICIs.

Differentiating Immune-Related Adrenal Insufficiency From Low Cardiac Output Syndrome: A Case Report.

We report a case of a 58-year-old woman with secondary adrenocortical insufficiency due to adrenocorticotropic hormone (ACTH) deficiency after pembrolizumab treatment that required differentiation from low cardiac output syndrome. The patient had chronic heart failure due to radiation cardiomyopathy and underwent implantation of cardiac resynchronization therapy defibrillator (CRT-D). One year ago, she was diagnosed with squamous cell lung cancer and started combination therapy with carboplatin, paclitaxel, and pembrolizumab. She was hospitalized for anorexia, nausea, and hypotension. A diagnosis of secondary hypoadrenocorticism due to isolated ACTH deficiency was made, and from the course of the disease, it was diagnosed as a side effect of immune checkpoint inhibitors (ICIs). As the indications for ICIs continue to expand, it is necessary to understand the screening and management of their side effects.

A case of Wolff-Parkinson-White syndrome in which two-dimensional speckle-tracking echocardiography was useful for identifying the location of the accessory atrioventricular pathway.

BACKGROUND: In Wolff-Parkinson-White (WPW) syndrome, accessory atrioventricular pathways (AP) result in abnormal pre-excitation around the atrioventricular annuli and produce a dyssynchronous contraction of cardiac chambers. Identification of the AP affects the outcome of catheter ablation. CASE SUMMARY: We report a case of WPW syndrome and paroxysmal atrial fibrillation in a 65-year-old man. Wolff-Parkinson-White syndrome Type B was suspected from lead V1, but when two-dimensional speckle-tracking echocardiography (2D-STE) was performed, a decrease in regional strain was observed in the anterior basal wall of the left ventricle. We identified the earliest site of atrioventricular conduction, and improvement in the regional strain at the site of ablation was observed after successful AP ablation. DISCUSSION: Various echocardiographic techniques have been investigated as non-invasive alternatives for AP localization. Longitudinal 2D-STE accurately identified contractile abnormalities associated with the AP, allowing us to non-invasively estimate the localization of the AP in WPW syndrome.

Tetany Exacerbating Heart Failure: A Case Report.

Tetany is characterized by numbness and stiffness in the hands and feet caused by hypocalcemia, hypomagnesemia, and hyperventilatory alkalosis, primarily at peripheral neuromuscular junctions. Although hypocalcemia is common in critically ill patients, its diagnosis of hypocalcemia is complicated and sometimes overlooked. We encountered an 82-year-old woman with tetany that exacerbated heart failure. Pain and respiratory failure due to tetany are conditions that can lead to exacerbation of heart failure. Chronic renal failure is frequently associated with chronic heart failure, and regular follow-up of calcium, phosphorus, and magnesium levels is necessary for such patients.

Takotsubo cardiomyopathy following mechanical thrombectomy for acute ischemic stroke: illustrative case.

BACKGROUND: Excess neurological stress by hemorrhagic stoke induces cardiomyopathy, namely takotsubo cardiomyopathy. Here, the authors report a case of takotsubo myopathy following mechanical thrombectomy for acute large vessel occlusion. OBSERVATIONS: A 73-year-old man was emergently brought to the authors' hospital because of left hemiparesis and consciousness disturbance. An ischemic lesion of the right cerebral hemisphere and the right internal carotid artery occlusion was revealed. Emergently, endovascular treatment was performed, and occlusion of the artery was reanalyzed. However, he suffered from hypotension with electrocardiogram abnormality. Subsequently, coronary angiography was performed, but the arteries were patent. The authors made a diagnosis of takotsubo cardiomyopathy. LESSONS: Endovascular recanalization for large cerebral artery occlusion is so effective that it is becoming widely used. Even in the successful recanalization, we need to care for the takotsubo cardiomyopathy.

Clarithromycin-induced Coronary Vasospasms Caused Acute Coronary Syndrome in a 19-year-old Male Patient.

A 19-year-old-man was admitted to our hospital with intermittent chest pain. The day before admission, he had been diagnosed with enteritis and prescribed clarithromycin. He had experienced severe chest pain three times after taking clarithromycin; thus, acute coronary syndrome (ACS) was suspected. Emergent coronary angiography showed normal coronary arteries; however, the result of a subsequent acetylcholine provocation test was positive. We diagnosed him to have ACS caused by coronary vasospasms and suspected clarithromycin-induced Kounis syndrome. Although more common in older patients, Kounis syndrome must be suspected and a thorough medication history should be taken whenever a patient complains of chest pain.

Asymptomatic Immune Checkpoint Inhibitor-associated Myocarditis.

We herein report the case of a 75-year-old man with asymptomatic immune checkpoint inhibitor (ICI)-associated myocarditis diagnosed on the basis of elevated levels of creatine kinase (CK), CK-myocardial band and troponin I (TNI). He was suspected of being complicated with myasthenia gravis (MG). High-dose prednisolone (PSL) is associated with a risk of MG exacerbation; therefore, PSL therapy was gradually increased from 5 mg/day to 20 mg/day, which resulted in the normalization of the TNI level, and no PSL-related side effects occurred. MG easily complicates myocarditis as an immune-related adverse event; thus, the treatment plan should be carefully considered.

A case of severe aortic stenosis caused by unicuspid unicommissural aortic valve.

Unicuspid aortic valve (UAV) is an extremely rare congenital malformation that frequently presents with valvular dysfunction or aortic aneurysm. Here we report the case of a 49-year-old man with severe aortic stenosis caused by UAV requiring the Bentall procedure. Two- and three-dimensional transesophageal echocardiography revealed an eccentric opening in an aortic valve and a lateral attachment to the aorta at the orifice level, suggestive of which is consistent with unicommissural UAV as confirmed by surgical findings. .

Essential Thrombocythemia in a Nonagenarian Presenting With Acute Myocardial Infarction.

Essential thrombocythemia (ET) is a chronic Philadelphia-negative myeloproliferative neoplasm (MPN) characterized by clonal thrombocytosis and an increased risk of arterial and venous thrombosis. Because ET has a low probability of progressing to acute leukemia or myelofibrosis and its prognosis is determined by thromboembolic or bleeding symptoms, the treatment of this disease is aimed at preventing vascular events. We encountered a nonagenarian patient with ET who presented with acute myocardial infarction with ST-segment elevation. In the present case, the patient was 91 years old, and antithrombotic agents were required after the placement of drug-eluting stent. Therefore, we decided not to perform cytoreductive therapy because the risk of bleeding is higher. Very elderly patients with ET are at an increased risk of thrombotic and hemorrhagic events. The risk-benefit of antithrombotic therapy should be considered individually.

Severe Gastroparesis After Ablation for Atrial Fibrillation.

A 70-year-old man was treated with catheter ablation for symptomatic paroxysmal atrial fibrillation (AF). The treatment consisted of pulmonary vein isolation and radiofrequency ablation of the cavo-tricuspid isthmus line. However, the patient started vomiting two days after ablation. Abdominal radiography and plain abdominal computed tomography revealed gastric distension and massive accumulation of food residues. Esophagogastroduodenoscopy after fasting for two days revealed no organic stricture; food residues were retained in the stomach but not in the duodenum, suggesting gastroparesis. The most likely mechanism underlying gastroparesis associated with AF ablation is collateral periesophageal vagal nerve injury. Mosapride citrate is considered effective for symptoms.