Trends and cardiovascular outcomes of Takotsubo syndrome with cardiogenic shock vs. mixed cardiogenic and septic shock: a nationwide propensity matched analysis.

INTRODUCTION: Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, can be complicated by shock. The outcomes of patients with TTS complicated with cardiogenic shock (CS) versus mixed cardiogenic and septic shock (MS) is not known. METHODS: We queried Nationwide Inpatient Sample (NIS) from 2009-2020 to compare TTS patients with CS and MS using International Classification of Disease, Ninth & Tenth Edition, Clinical Modification (ICD- 9 & 10-CM) coding. In-hospital outcomes were compared using one: one propensity score matched (PSM) analysis. The primary outcome was in-hospital mortality. RESULTS: Of 23,126 patients with TTS 17,132 (74%) had CS, and 6,269 (26%) had MS. The mean age was 67 years in CS and 66 years in MS, and majority of patients were female (n = 17,775, 77%). On adjusted multivariate analysis, MS patients had higher odds of in-hospital mortality (aOR 1.44, 95% CI 1.36-1.52), AKI (aOR 1.53, 95% CI 1.48-1.58), pressor requirement (aOR 1.37, 95% CI 1.25-1.50). However, had lower odds of MCS use (aOR 0.44, 95% CI 0.40-0.48) and cardiac arrest (aOR: 0.81, 95% CI 0.73-0.90) (p-value <0.0001). Mean LOS and inflation-adjusted hospital charges were higher in MS. CONCLUSION: MS in the setting of TTS have higher rates of in-hospital mortality, AKI, and pressor requirements.

Comparative Effectiveness of Direct Current Cardioversion in Patients With Atrial Fibrillation and Obesity With Body Mass Index ≥50 kg/m2.

Atrial fibrillation is one of the most frequently encountered arrhythmia, with obesity being an independent risk factor. There are sparse data on the success rates of direct current cardioversion (DCCV) in patients with severe obesity. We compared the effectiveness of DCCV in patients with a body mass index (BMI) >50 kg/m2 with those with a BMI <30 kg/m2. A retrospective chart review of 111 patients was performed between January 1, 2011 and January 1, 2022. The study cohort was stratified into 2 groups: BMI ≥50 kg/m2 and BMI <30 kg/m2. The primary outcome was successful achievement of normal sinus rhythm after DCCV. The secondary outcomes included number of attempted shocks, number of successful shocks on first attempts, and energy of successful shock. The primary outcome occurred in 94.6% of patients with a BMI <30 kg/m2 group compared with 81.8% in the patients with a BMI ≥50 kg/m2 (p = 0.042). Patients in the higher BMI cohort had a higher median energy during a successful shock than the lower BMI cohort (250 J [200 to 360 J] vs 200 J [150 to 200 J], p <0.001). There was no difference in the number of shocks used between the 2 groups or in the success of the first shock delivered between BMI ≥50 kg/m2 and BMI <30 kg/m2 (75% vs 58.2%, p = 0.093). In conclusion, patients with a BMI ≥50 kg/m2 had lower rates of successful DCCV than patients with a BMI <30 kg/m2; therefore, clinicians must be aware of the alternative strategies to improve DCCV success and the possibility of DCCV failure in patients with higher BMIs.

Association Between Social Vulnerability Index and Mortality Following Acute Myocardial Infarction in the US Counties.

Social determinants of health (SDOH) play a major role in cardiovascular outcomes. The social vulnerability index (SVI) is a tool designed by the Center for Disease Control (CDC) to measure a community's vulnerability to respond and recover from disasters. The parameters of SVI can be used to gauge social disparities amongst different US counties and its association with acute myocardial infarction (AMI) related to age- adjusted mortality rate (AAMR) by using the multiple causes of death database from CDC, Prevention's Wide-Ranging Online Data for Epidemiological Research (WONDER 2016-2020) and Agency for Toxic Substances and Disease Registry (ATSDR). We used segmented regression models to evaluate the association between quintiles of SVI scores and AAMR using STATA. A total of 2908 of 3289 US counties were used in the analysis. The mean AAMR was 89.3 per 100,000 (95% CI: 87.1-91.5) from 2016 to 2020. US counties with higher SVI were associated with higher AMI-related age-adjusted mortality when compared to counties with lower SVI. Counties with the highest SVI and AAMR were in the mid-western and southern states The findings of our study can guide focused care for a uniform upliftment of CV health across the nation by identifying the distribution of socio-economically disadvantaged counties.

In-Hospital Outcomes of COVID-19 Associated Myocarditis (from a Nationwide Inpatient Sample Database Study).

The prevalence of COVID-19 infection-related myocarditis, its in-hospital cardiovascular outcomes, and its impact on hospital cost and stay at national level are not well studied in the literature. The Nationwide Inpatient Sample Database from 2020 was queried to identify patients with COVID-19 and myocarditis versus those without myocarditis. Cardiovascular outcomes and resource utilization were studied among cohorts with COVID-19, with and without myocarditis, using descriptive statistics, multivariate regression matching, and propensity score matching using STATA version 17. Of 1,678,995 patients, 3,565 (0.21%) had COVID-19 with myocarditis, and 1,675,355 (99.78%) had COVID-19 without myocarditis. On multivariate regression analysis, we found higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.27 to 1.9) in patients with myocarditis than in those without myocarditis, in addition to higher odds of major adverse cardiovascular and cerebrovascular events (aOR 3.54, 95% CI 2.8 to 4.4), acute kidney injury (aOR 1.29, 95% CI 1.27 to 1.9), heart failure (aOR 2.77, 95% CI 2.3 to 3.4), cardiogenic shock (aOR 10.2, 95% CI 7.9 to 13), myocardial infarction (aOR 5.74, 95% CI 4.5 to 7.3), and use of mechanical circulatory support (aOR 2.81, 95% CI 1.6 to 4.9). The propensity-matched cohort also favored similar outcomes. In conclusion, patients with COVID-19 and myocarditis had worse clinical outcomes, having a higher rate of in-hospital mortality, major adverse cardiovascular and cerebrovascular events with longer length of hospital stay, and higher hospitalization costs. Large prospective trials are necessary to validate these findings with diagnostic measures, including biopsy and cardiac magnetic resonance imaging for the extent of myocardial involvement.

Multimodality assessment of high- vs. low-gradient aortic stenosis using echocardiography and cardiac CT.

BACKGROUND: Aortic valve area (AVA) using CT-LVOT area (AVACT-LVOT) <1.2 â€‹cm2 has been shown comparable to echocardiography AVA of <1.0 â€‹cm2 for severe aortic stenosis (AS). Current study evaluates how AS diagnosis will be affected when we substitute CT-LVOT with echo derived LVOT. METHODS: We retrospectively studied 367 patients who underwent cardiac CTA and echocardiogram for assessment of high- and low-gradient AS (HG-AS and LG-AS). AVACT-LVOT was derived from CT-LVOT area and echo doppler data. Three AVACT-LVOT categories were created (<1.0, 1.0-1.2 and â€‹> â€‹1.2 â€‹cm2). Outcomes were defined as composite of all-cause mortality and/or valve intervention. RESULTS: Median echocardiographic profiles were consistent with severe AS across three AVACT-LVOT categories for HG-AS. HG-AS patients with AVACT-LVOT >1.2 â€‹cm2 had larger median CT-LVOT area (5.06 â€‹cm2) and AVC (2917AU). Among LG-AS with AVACT-LVOT â€‹≤1.2 cm2, 57% met echo criteria for low-flow LG-AS and 63% met criteria for severe AS using aortic valve calcium (AVC). Additionally, 45% with AVACT-LVOT >1.2 â€‹cm2 had larger median CT-LVOT area (5.43 â€‹cm2) and AVC (2389AU). Patients with AVACT-LVOT >1.2 â€‹cm2 and high AVC had large body surface area and were mostly characterized as severe with indexed AVA and AVC. Stroke volume index using CT-LVOT reclassified 70% of low-flow, LG-AS as normal flow, LG-AS. Composite outcomes were higher among patients with AVACT-LVOT ≤1.2 â€‹cm2 (p â€‹< â€‹0.01), however, with no superior net reclassification improvement compared to AVAecho <1.0 â€‹cm2. CONCLUSION: AVACT-LVOT ≤1.2 â€‹cm2 is a reasonable CT criterion for severe AS. Large LVOT with elevated AVC identified a severe AS phenotype despite an AVACT-LVOT >1.2 â€‹cm2, best characterized by indexed AVA and AVC.

Delayed Recurrence of Chromophobe Renal Cell Carcinoma Presenting as Metastatic Duodenal Ulcer.

Renal cancers are one of the common causes of cancer-related morbidity and mortality worldwide. Most primary cases are localized at presentation and are treated with partial or radical nephrectomy with curative intent. However, renal cell carcinoma (RCC) is known for its potential recurrence, sometimes several years after initial management. Many of these recurrent cases commonly metastasize to the liver, kidney, or bone and herald a poor prognosis. We present a case study of nonclear cell RCC, which recurred 33 years after nephrectomy and masqueraded as a duodenal ulcer -- an extremely rare site for metastasis. This is unique as it describes a presentation only sparingly documented in the medical literature and highlights a more extended period of recurrence than currently reported. Moreover, our patient's tumor was chromophobe cell variety, a rare sub-type of nonclear cell RCC, which to our knowledge has never been known to cause duodenal metastasis. Studies have implicated a prognostic role of lymph node involvement at the time of initial diagnosis to predict future recurrence. This case is a drop in the mighty ocean to prompt further investigation on the utility of life-long surveillance protocols and further research evaluating the role of lymph node dissection in preventing such recurrences and high mortality.

Aerococcus Urinae Aortic Valve Endocarditis with Kissing Aortic Wall Ulcer: A Case Report and Literature Review.

BACKGROUND Initially presumed as nonpathogenic, the bacterial genus aerococcus now includes 7 distinct virulent and avirulent species. Aerococcus urinae first isolated in 1992 is an uncommon cause of urinary tract infection (UTI) and is seen in only 0.15% to 0.8% of cases. A. urinae associated invasive bacteremia and systemic infection are extremely rare entities. Less than 50 cases of A. urinae associated with infective endocarditis (IE) have been reported in the literature, with the prevalence being 3 per 1 million. CASE REPORT A 59-year-old male presented to our hospital with exertional dyspnea and new-onset atrial flutter. Prior to his current admission patient was treated for A. urinae associated UTI with levofloxacin for 10 days. A transthoracic echocardiogram revealed severe aortic regurgitation with aortic valve endocarditis, which was subsequently confirmed on transesophageal echocardiogram. Blood cultures displayed gram-positive cocci in clusters, ultimately identified as A. urinae. The patient was treated with intravenous vancomycin and underwent surgical aortic valve replacement along with patch repair for underlying aortic wall ulcer. CONCLUSIONS To the best of our knowledge, this is the first-ever reported case of A. urinae associated IE complicated by an aortic wall ulcer. Male gender, age >65 years, and preexisting urinary tract pathology have all been implicated as risk factors for aerococcus infection. A. urinae is almost always sensitive to penicillin, carbapenem, and aminoglycosides.

Atypical Takotsubo Cardiomyopathy with Hypokinetic Left Mid-ventricle and Apical Wall Sparing: A Case Report and Literature Review.

BACKGROUND: Takotsubo Cardiomyopathy (TTC) is an uncommon cause of acute reversible ventricular systolic dysfunction in the absence of obstructive Coronary Artery Disease (CAD). Typically manifesting as apical wall ballooning, TTC can rarely present atypically with apical wall sparing. CASE REPORT: A 62-year-old female presented with complaints of chest pain and features mimicking acute coronary syndrome. Coronary angiogram revealed no obstructive CAD and left ventriculogram showed reduced ejection fraction, normal left ventricular apex and hypokinetic mid-ventricles consistent with atypical TTC. The patient was discharged home on heart failure medications and a follow-up transthoracic echocardiogram demonstrated improved left ventricular function with no wall motion abnormality. CONCLUSION: This case report provides an insight into the diagnosis and management of TTC in the absence of pathognomic features.

Anomalous origin of left main coronary artery from right coronary artery in a patient presenting with inferior wall myocardial infarction: a case report and literature review.

BACKGROUND: Anomalous origin of the coronary arteries is seen in less than 1% of the general population. Single coronary artery (SCA) is a congenital anatomic abnormality identified by a single coronary ostium giving rise to one coronary artery. We present an extremely rare variant of the left main coronary artery (LMCA) branching off from the right coronary artery (RCA) and following a prepulmonic course. CASE SUMMARY: A 72-year-old woman presented due to ongoing chest pain with associated ST-segment elevation involving the inferior leads. Emergent cardiac catheterization revealed a 99% ulcerated lesion in distal RCA, which was intervened on with angioplasty and stent placement. The RCA was noted giving rise to LMCA, which followed a prepulmonic course (anterior to pulmonary artery) before trifurcating into a small caliber left anterior descending, ramus intermedius, and hypoplastic left circumflex arteries. The non-malignant course of the aberrant LMCA was confirmed on the coronary computed tomography angiogram. The patient was discharged home on guideline-directed medical therapy. DISCUSSION: The patient illustrated congenital SCA with type RIIA pattern of the aberrant vessel based on the Lipton anatomic classification for SCA. The prepulmonic course of SCA is usually benign and can be managed conservatively.

Obesity Paradox in Peripheral Arterial Disease: Results of a Propensity Match Analysis from the National Inpatient Sample.

Introduction The role of obesity in cardiovascular mortality is controversial. The obesity paradox has been widely attributed to smoking in the underweight. Large-scale studies analyzing the outcomes of peripheral arterial disease (PAD) in patients with a higher body mass index (BMI) while accounting for confounders such as smoking are lacking. Method The 2016 National Inpatient Sample (NIS) was used to identify all admissions with a primary discharge diagnosis of PAD. A secondary diagnosis of obesity or elevated BMI was used to segregate the admissions into two groups. Propensity scores were calculated to match and control both groups for age, smoking, and diabetes, amongst other confounders. A multivariate logistic and linear regression analysis was performed to calculate the odds ratio for in-hospital mortality, amputation, need for intervention (angioplasty or bypass), acute kidney injury, hospital charges, and length of stay. Non-obesity-related PAD admissions were selected as the reference groups. Results Among 248,288 PAD-related admissions, 41,618 had a secondary diagnosis of obesity. After calculating propensity scores for 1-1 matching, 41,589 admissions in the PAD and obesity group were compared to a similar number of admissions in the reference population. Patients with a concomitant diagnosis of obesity had lower odds of amputation (OR=0.90, 95% CI=0.84-0.95, p<0.001), need for intervention (OR=0.66, 95% CI=0.62-0.69, p<0.0001), and in-hospital mortality (OR=0.81, 95% CI=0.74-0.87, p<0.0001). On the contrary, the odds of having acute kidney injury were higher with elevated BMI (OR=1.30, 95% CI=1.26-1.34, p<0.0001). Conclusion Despite increasing the risk of hypertension, diabetes, and hypertriglyceridemia, the obesity paradox continues to exist with a better short-term prognosis in patients with PAD. Future studies looking into the pathophysiology behind this phenomenon are needed.

Evaluation of Mitral Apparatus Blood Cyst: A Case Report and Review of Literature.

Intracardiac blood cysts (ICBC) are cardiac pseudoneoplasm commonly seen in infants below two months of age. ICBC typically resolve spontaneously; however, they can sometimes persist in adults and can cause detrimental consequences. A 47-year-old female presented to our facility with complaints of chest pain and was found to have an incidental subvalvular chordal mitral apparatus echolucent mass on transthoracic echocardiogram (TTE). A stress echocardiography was performed, which revealed transient left ventricle outflow tract (LVOT) obstruction in the absence of anginal symptoms. A cardiac magnetic resonance imaging (MRI) showed no evidence of increased mass enhancement confirming the diagnosis of a benign blood cyst of mitral apparatus. The cyst was treated conservatively with carvedilol to prevent worsening of exertional LVOT obstruction. A follow-up study done at six months showed stable exertional hemodynamics. There is no general consensus while managing ICBC. In asymptomatic, non-surgical patients stress echocardiography can offer valuable information by assessing the hemodynamic implications resulting from the cyst.

Implications of Left Bundle Branch Block in Takotsubo Cardiomyopathy: Propensity Match Analysis from the National Inpatient Sample.

INTRODUCTION: Takotsubo cardiomyopathy (TTC), also called stress cardiomyopathy, is a transient reversible left ventricular dysfunction mimicking acute coronary syndrome (ACS). Studies have shown similar rates of in-hospital complications in TTC and myocardial infarction (MI). Left bundle branch block (LBBB) is associated with increased mortality in patients with MI; however, similar studies comparing outcomes of TTC in the presence of LBBB are lacking. METHODS: The 2016 National Inpatient Sample (NIS) database was queried to identify all admissions with a primary discharge diagnosis of TTC. Diagnosis-specific codes were used to stratify patients based on the presence or absence of LBBB. Both population sets were paired using 1:10 propensity score matching. Multivariate logistic regression analysis was performed to compare various in-hospital outcomes among both groups. RESULTS: Amongst 7270 admissions for TTC, 226 patients had concomitant LBBB. After performing 1:10 propensity matching, 130 patients with LBBB were compared to 1275 patients without LBBB. The presence of LBBB was associated with increased odds of cardiogenic shock (AOR = 2.2, 95% CI 1.21-3.99, p = 0.0097); ventricular arrhythmia (AOR 1.99, 95% CI 1.11-3.57, p = 0.02), acute congestive heart failure (AOR = 1.49, 95% CI 1.01-2.2, p = 0.04), and sudden cardiac arrest (AOR = 3.37, 95% CI 1.59-7.13, p = 0.0001). There was no statistical difference in all-cause in-hospital mortality, however a trend towards worsening was noted. CONCLUSIONS: The incidence of arrhythmia and shock in patients with TTC does not correlate with the extent of myocardium involvement. The presence of LBBB in such cases can help recognize at-risk populations, and with timely intervention, life-threatening complications can be avoided. Despite limitations of the dataset and inability to establish causality, prospective studies with longer follow-up are warranted.

Pregnancy unmasking symptoms of undiagnosed lymphangioleiomyomatosis: Case report and review of literature.

Cystic lung diseases are a group of disorders that appear similar on radiological studies on chest computed tomography. Each disorder is characterized by its own etiology, pathophysiology, course of progression and manifestation. Lymphangioleiomyomatosis (LAM) is one of the cystic lung diseases that can either be hereditary or sporadic. The sporadic form is a rare disease with no accurate prevalence reported but is believed to be less than 10 per million. LAM is associated with inappropriate activation of mammalian target of rapamycin (mTOR) signaling which regulates cellular growth. The sporadic form is almost confined to premenopausal female population and estrogen is believed to play an important role in the pathogenesis. Pregnancy and use of estrogen based oral contraceptives can aggravate symptoms of already existing LAM. Here we describe a case of LAM that was previously treated as asthma and was diagnosed after exacerbation of respiratory symptoms after pregnancy. We offer a review of the medical literature regarding the etiology, clinical course, diagnosis and treatment of LAM.