A wobble tachycardia supraventricular, ventricular or both?

We present the case of a 77-year-old man with ischemic heart disease and baseline right bundle branch block having a well-tolerated and regular wide complex tachycardia with right bundle branch block morphology. A wide complex tachycardia (WCT) could be of supraventricular or ventricular origin. In this setting, we discuss the differential diagnosis of WCT, the usefulness and limitations of the diagnostic criteria for ventricular tachycardia.

Fulminant myocarditis following SARS-CoV-2 mRNA vaccination rescued with venoarterial ECMO: A report of two cases.

INTRODUCTION: Cases of myocarditis after COVID-19 messenger RNA (mRNA) vaccines administration have been reported. Although the majority follow a mild course, fulminant presentations may occur. In these cases, cardiopulmonary support with venoarterial extracorporeal membrane oxygenation (V-A ECMO) may be needed. RESULTS: We present two cases supported with V-A ECMO for refractory cardiogenic shock due to myocarditis secondary to a mRNA SARS-CoV2 vaccine. One of the cases was admitted for out-of-hospital cardiac arrest. In both, a peripheral V-A ECMO was implanted in the cath lab using the Seldinger technique. An intra-aortic balloon pump was needed in one case for left ventricle unloading. Support could be successfully withdrawn in a mean of five days. No major bleeding or thrombosis complications occurred. Whereas an endomyocardial biopsy was performed in both, a definite microscopic diagnosis just could be reached in one of them. Treatment was the same, using 1000mg of methylprednisolone/day for three days. A cardiac magnetic resonance was performed ten days after admission, showing a significant improvement of the left ventricular ejection fraction and diffuse oedema and subepicardial contrast intake in different segments. Both cases were discharged fully recovered, with CPC 1. CONCLUSIONS: COVID-19 vaccine-associated fulminant myocarditis has a high morbidity and mortality but presents a high potential for recovery. V-A ECMO should be established in cases with refractory cardiogenic shock during the acute phase.

Left atrial deformation analysis in patients with non-ischaemic dilated cardiomyopathy in atrial fibrillation.

Aims: Atrial fibrillation (AF) is a common comorbidity in non-ischaemic dilated cardiomyopathy (NIDCM) affecting conventional measures of left atrial (LA) function. We aimed to determine whether LA function analysis could identify patients at higher risk of major cardiovascular events (MACEs). Methods and results: A retrospective study of patients with NIDCM in AF referred to a single centre for transthoracic echocardiography (TTE) between 2015 and 2019. Peak atrial longitudinal strain (PALS) was measured along with LA emptying fraction and LA filling index (LAFI = E wave/PALS). Cox regression analysis was conducted. A total of 153 patients were included [median age 74 years, left ventricular ejection fraction (LVEF) 35%], and 57 (37.3%) had MACE after a median follow-up of 3.2 years. LAFI was the only independent TTE parameter associated with MACE after adjustment for age, diabetes, LVEF, left ventricular global longitudinal strain (LV-GLS), and LA volume index [adjusted hazard ratio (HR) = 1.02 per point increase, P = 0.024], with the best cut-off at ≥15. LAFI ≥15 predicted each of MACE components when separately analysed: MACE HR = 1.95, 95% confidence interval (CI) 1.16-3.30; cardiovascular death HR = 3.68, 95% CI 1.41-9.56, heart failure admission HR = 2.13, 95% CI 1.19-3.80, and ventricular arrhythmia HR = 4.72, 95% CI 1.52-14.67. Higher LAFI was associated with worsening LV-GLS, E/e', systolic pulmonary artery (PA) pressure, tricuspid annular plane systolic excursion, and right ventricular to PA coupling. Conclusion: LA deformation analysis is feasible in patients with NIDCM presenting with AF. LAFI may identify patients at higher risk of MACE and correlates with higher pulmonary pressures and worse right ventricular function, suggesting an elevation of left-sided ventricular pressures in patients with higher LAFI.

Endomyocardial involvement in asymptomatic Latin American migrants with eosinophilia related to helminth infection: A pilot study.

BACKGROUND: Hypereosinophilic syndrome can produce cardiac involvement and endomyocardial fibrosis, which have a poor prognosis. However, there is limited information regarding cardiac involvement among migrants from Latin America with eosinophilia related to helminthiasis. METHODS: We conducted a pilot observational study where an echocardiography was performed on migrants from Latin America with both eosinophilia (>450 cells/µL) and a diagnosis of helminth infection, and on migrants from Latin America without eosinophilia or helminth infection. Microbiological techniques included a stool microscopic examination using the Ritchie's formalin-ether technique, and a specific serology to detect Strongyloides stercoralis antibodies. RESULTS: 37 participants were included, 20 with eosinophilia and 17 without eosinophilia. Twenty (54.1%) were men with a mean age of 41.3 (SD 14.3) years. Helminthic infections diagnosed in the group with eosinophilia were: 17 cases of S. stercoralis infection, 1 case of hookworm infection, and 2 cases of S. stercoralis and hookworm coinfection. Among participants with eosinophilia, echocardiographic findings revealed a greater right ventricle thickness (p = 0.001) and left atrial area and volume index (p = 0.003 and p = 0.004, respectively), while showing a lower left atrial strain (p = 0.006) and E-wave deceleration time (p = 0.008). An increase was shown in both posterior and anterior mitral leaflet thickness (p = 0.0014 and p = 0.004, respectively) when compared with participants without eosinophilia. CONCLUSIONS: Migrants from Latin America with eosinophilia related to helminthic infections might present incipient echocardiographic alterations suggestive of early diastolic dysfunction, that could be related to eosinophilia-induced changes in the endomyocardium.

Risk of Stroke and Incident Atrial Fibrillation in Patients in Sinus Rhythm With Non-Ischemic Dilated Cardiomyopathy.

BACKGROUND: Non-ischemic dilated cardiomyopathy (NIDCM) is associated with an increased risk of atrial fibrillation (AF) and stroke, especially in patients with high CHA2DS2-VASc. We aimed to identify variables associated with incident AF or stroke using left atrial (LA) deformation analysis and its prognostic value added to CHA2DS2-VASc score. Patients with NIDCM and LVEF <50% in sinus rhythm were included between January 2015 and December 2019. LA volume index (LAVI) and atrial strain were used in combination with the CHA2DS2-VAS score to predict ischemic stroke or incident AF. Proportional hazards Cox regression was used to provide hazard ratios (HR). There were 338 patients included. After a median follow-up of 3.6 years, the endpoint occurred in 41 (12.1%) patients. LAVI outperformed other echocardiographic parameters, with significant improvement in risk reclassification compared to CHA2DS2-VASc alone (net reclassification index 0.6, increase in Harrell's C from 0.63 to 0.73, P=0.003) and remained significant after multivariate adjustment. LAVI was associated with both components of the endpoint separately. The best cutoff for LAVI was 44 ml/m2. LAVI ≥44ml/m2 increased the risk of the endpoint among those with CHA2DS2-VASc ≥3 (HR=6.0, 95%CI 2.6-13.5), but not in those with CHA2DS2-VASc <3 (HR=1.2, 95%CI 0.3-4.5). Competing risk analysis did not alter the results. In conclusion, LAVI might be used to assess the risk of incident AF or stroke in NIDCM. Patients with LAVI ≥44 ml/m2 and CHA2DS2-VASc ≥3 could be at high risk of AF and stroke and may benefit from more intensive surveillance.

Revascularization and outcomes in ischaemic left ventricular dysfunction after heart failure admission: The RevascHeart study.

AIMS: Despite numerous trials on revascularization in patients with heart failure (HF) and ischaemic left ventricular (LV) dysfunction, its role remains unsettled. Guideline-directed medical therapy (GDMT) for HF has shown benefits on outcomes. This multicentre study aims to compare long-term mortality between revascularization and GDMT in patients with ischaemic LV dysfunction following admission for HF. METHODS AND RESULTS: Between 2012 and 2023, 408 patients admitted for HF with a LV ejection fraction (LVEF) of 40% or less and documented coronary artery disease (CAD) were included. Patients were categorized into two groups based on their initial treatment decision: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) or GDMT. The primary outcome was rate of all-cause or cardiovascular mortality, and secondary outcomes included type of revascularization (PCI vs. CABG) and LV reverse remodelling. After a median 44.6-month follow-up, 100 patients (33%) died in the revascularization group, compared to 44 (43%) in the GDMT group. Multivariate analysis showed no significant benefit of revascularization on all-cause mortality (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.48-1.39, p = 0.45) or cardiovascular mortality (HR 0.97, 95% CI 0.62-1.52, p = 0.90) compared to GDMT. Neither CABG (HR 0.74, 95% CI 0.51-1.08, p = 0.13) nor PCI (HR 0.98, 95% CI 0.62-1.55, p = 0.93) demonstrated a mortality reduction compared to GDMT. Both groups experienced significant reductions in LV size and improvements in LVEF, greater in the revascularization group. CONCLUSION: Revascularization did not outperform GDMT in ischaemic LV dysfunction following HF admission in this retrospective analysis. Larger prospective studies are needed to clarify the potential role of revascularization in improving outcomes.

Transcatheter aortic valve replacement for acute aortic regurgitation due to Staphylococcus aureus infective endocarditis complicated with a perivalvular abscess: a case report.

Background: Infective endocarditis is a life-threatening disease associated with high mortality. Appropriate antimicrobial treatment and cardiac surgery, when indicated, are closely related to prognosis. When cardiac surgery is contraindicated, prognosis worsens dramatically. There is few data concerning the use of transcatheter aortic valve replacement after healed aortic valve endocarditis or during active IE. We present the first case report of a transcatheter aortic valve replacement implanted during antimicrobial therapy for a severely symptomatic acute aortic regurgitation due to an infective endocarditis complicated with a perivalvular abscess. Case summary: A 68-year-old man was admitted due to left hemiparesis and fever. An acute ischaemic stroke with haemorrhagic transformation was diagnosed. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus and a transoesophageal echocardiogram revealed an aortic endocarditis with an acute severe aortic regurgitation and a perivalvular abscess. Urgent cardiac surgery was contraindicated due to intracranial haemorrhage. However, the patient developed refractory pulmonary oedema and haemodynamic instability. Despite the perivalvular abscess, a transcatheter aortic valve replacement was successfully performed 15 days after the diagnosis. Nine months after completing antimicrobial therapy, there were no signs of relapse. Discussion: Transcatheter aortic valve replacement could be considered in selected patients with symptomatic severe aortic regurgitation due to aortic infective endocarditis during antimicrobial therapy when cardiac surgery is contraindicated.