A spectrum of sinus of Valsalva aneurysm-From the young to the old.

Sinus of Valsalva aneurysm (SVA) is a rare but potentially serious condition. Proper and timely diagnosis is crucial to the outcome of patients, particularly when rupture has occurred. Echocardiography is often the initial diagnostic imaging modality of choice as it is ubiquitous, relatively inexpensive, and without need for radiation or iodinated contrast administration. There are several congenital abnormalities that can appear similar to SVA on echocardiography, making the diagnosis challenging especially if providers are unfamiliar with these conditions. Here, we present a case series of three patients with SVA, representing a wide spectrum ranging from a young man presenting with acute rupture and decompensated heart failure to an elderly asymptomatic male with an incidental unruptured aneurysm. We will also present a brief literature overview and our approach to differentiating SVA from other congenital abnormalities on echocardiography.

Meta-Analysis of Prophylactic Renal Replacement Therapy after Cardiac Catheterization in Patients with Chronic Kidney Disease.

BACKGROUND: The benefits of prophylactic renal replacement therapy after cardiac catheterization in patients with chronic kidney disease remain unclear. The aim of this study is to confirm the benefit of prophylactic renal replacement therapy after cardiac catheterization. METHODS: We systematically searched for studies published from inception to December 2022 examining the benefits of prophylactic renal replacement therapy after cardiac catheterization in MEDLINE and EMBASE. Data analysis was performed according to the PRISMA statement using the Mantel-Haenszel method. RESULTS: Five studies met the inclusion criteria, which comprised of 532 chronic kidney disease patients who underwent coronary angiography (268 had prophylactic renal replacement therapy and 264 did not have prophylactic renal replacement therapy). The pooled analysis revealed a non-significant decreased risk of 1-year mortality in chronic kidney disease patients who underwent coronary angiography and prophylactic renal replacement therapy compared to those who did not have prophylactic renal replacement therapy (RR = 0.59; P =.18; CI: 0.28-1.2795, I2 = 60.4%). The risk of hemodialysis during hospitalization and renal replacement therapy requirement in 1 year in chronic kidney disease patients who underwent coronary angiography and prophylactic renal replacement therapy were lower than in those who did not have prophylactic renal replacement therapy (RR = 0.13; P =.001; CI: 0.04-0.43, I2 = 9.1% and RR = 0.29; P =.015; CI: 0.11-0.78, I2 = 49.9%, respectively). The sensitivity analysis demonstrated that the overall findings remained consistent and did not significantly alter. CONCLUSIONS: Prophylactic renal replacement therapy did not seem to lower 1-year mortality among chronic kidney disease patients who underwent coronary angiography. However, prophylactic renal replacement therapy appeared to reduce the risk of hemodialysis during hospitalization and renal replacement therapy requirement in 1 year.

Monitoring of Metabolic Syndrome and Cardiovascular Disease in Childhood Cancer Survivors.

Advances in cancer treatment have significantly improved childhood cancer survival, although metabolic syndrome and cardiovascular disease are common long-term complications that may occur years after treatment. Childhood cancer survivors may not receive appropriate follow-up due to lack of communication between oncologists and primary care physicians, or, from lack of awareness of possible long-term metabolic and cardiovascular complications after cancer treatment. We, therefore, reviewed current evidence on long-term effects of cancer therapy, and appropriate monitoring for long-term treatment effects in childhood cancer survivors that could lead to early detection and prompt treatment to prevent future cardiovascular events.

Reactogenicity and immunogenicity of the intradermal administration of BNT162b2 mRNA vaccine in healthy adults who were primed with an inactivated SARS-CoV-2 vaccine.

Because of the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), safe and effective vaccines are urgently required. The shortage of effective vaccines is a major challenge in many developing countries. We studied intradermal (ID) fractional dose BNT162b2 mRNA (Comirnaty®, Pfizer-BioNTech) as a booster dose in healthy adults who were previously immunized with an inactivated SARS-CoV-2 vaccine. This is a retrospective cohort study that included healthy adults who were immunized with two doses of inactivated SARS-CoV-2 vaccine and received a booster dose with ID fractional dose or intramuscular (IM) full-dose BNT162b2 mRNA between August 1 to August 15, 2021. The primary endpoint was safety that included local and systemic adverse reactions. The secondary endpoints were levels of SARS-CoV-2 spike protein receptor-binding domain IgG antibody (anti-S-RBD IgG) and neutralizing antibody activity against the Delta variant (B.1.617.2) using surrogate viral neutralization test (sVNT) 3 weeks after the booster dose. A total of 43 healthy adults (median age of 31 years) were included in the study; among them, 23 participants received ID fractional dose (6 µg) BNT162b2 mRNA, and 20 participants received IM full-dose (30 µg) BNT162b2 mRNA. No serious adverse reactions were observed. Local adverse reactions occurred more frequently in the ID group. No differences were observed in the baseline level of anti-S-RBD IgG (289 vs 286 AU/mL, p > 0.9, in the ID and IM groups, respectively). After booster, anti-S-RBD IgG titer increased to 13294 (9255-19573) AU/mL in the ID group and 23456 (16943-38539) AU/mL in the IM group. All participants in the IM group and 95.6 % of participants in the ID group had seroconversion evaluated by sVNT (≥68 % inhibition to the Delta variant). ID administration of BNT162b2 mRNA was safe and well-tolerated and generated a robust immune response. Therefore, ID delivery of the BNT162b2 mRNA vaccine has the potential for a dose-sparing strategy.

Use of heparin alone in treating pulmonary emboli found in association with in-transit right-heart thrombi in a nonagenarian.

In patients who present with pulmonary embolism, right-heart thrombus is a rare condition that is associated with increased mortality rates, compared with pulmonary embolism alone. Thrombolytic therapy has been associated with a survival benefit in previous studies of pulmonary embolism arising from right-heart thrombus. However, older patients have been excluded from such studies because thrombolysis places them at excessively high risk of bleeding. We present a case, in a 92-year-old woman, of pulmonary embolism arising from right-heart thrombi that we successfully treated with heparin.

Agreement between ICU clinicians and electrophysiology cardiologists on the decision to initiate a QTc-interval prolonging medication in critically ill patients with potential risk factors for torsade de pointes: a comparative, case-based evaluation.

STUDY OBJECTIVES: To measure concordance between different intensive care unit (ICU) clinicians and a consensus group of electrophysiology (EP) cardiologists for use of a common rate-corrected QT interval (QTc)-prolonging medication in cases containing different potential risk factor(s) for torsade de pointes (TdP). DESIGN: Prospective case-based evaluation. SETTING: Academic medical center with 320 beds. SUBJECTS: Medical house staff (MDs) and ICU nurses (RNs) from one center and select critical care pharmacists (PHs). INTERVENTION: Completion of a survey containing 10 hypothetical ICU cases in which patients had agitated delirium for which a psychiatrist recommended intravenous haloperidol 5 mg every 6 hours. Each case contained different potential risk factor(s) for TdP in specific combinations. A group of five EP cardiologists agreed that haloperidol use was safe in five cases and not safe in five cases. MEASUREMENTS AND MAIN RESULTS: For each case, participants were asked to document whether they would administer haloperidol, to provide a rationale for their decision, and to state their level of confidence in that decision. Most clinicians (92 of 115 [80%]) invited to participate completed the cases. Among the five cases where EP cardiologists agreed that haloperidol was not safe, 29% of respondents felt that haloperidol was safe. Conversely, in the five cases where EP cardiologists felt haloperidol was safe, 21% of respondents believed that it was not safe. Overall respondent-EP cardiologist agreement for haloperidol use across the 10 cases was moderate (κ = 0.51). MDs and PHs were in agreement with the EP cardiologists more than RNs (p=0.03). Interprofessional variability existed for the TdP risk factors each best identified. Clinician confidence correlated with EP cardiologist concordance for MDs (p=0.002) and PHs (p=0.0002), but not for RNs (p=0.69). CONCLUSION: When evaluating use of a QTc interval-prolonging medication, ICU clinicians often fail to identify the TdP risk factors that EP cardiologists feel should prevent its use. Clinician-EP cardiologist concordance varies by the specific risk factor(s) for TdP and the ICU professional conducting the assessment.