Are Sodium-Glucose Cotransporter-2 Inhibitors the Cherry on Top of Cardio-Oncology Care?

The increasing aging of the population combined with improvements in cancer detection and care has significantly improved the survival and quality of life of cancer patients. These benefits are hampered by the increase of cardiovascular diseases being heart failure the most frequent manifestation of cardiotoxicity and becoming the major cause of morbidity and mortality among cancer survivor. Current strategies to prevent cardiotoxicity involves different approaches such as optimal management of CV risk factors, use of statins and/or neurohormonal medications, and, in some cases, even the use of chelating agents. As a class, SGLT2-i have revolutionized the therapeutic horizon of HF patients independently of their ejection fraction or glycemic status. There is an abundance of data from translational and observational clinical studies supporting a potential beneficial role of SGLT2-i in mitigating the cardiotoxic effects of cancer patients receiving anthracyclines. These findings underscore the need for more robust clinical trials to investigate the effect on cardiovascular outcomes of the prophylactic SGLT2-i treatment in patients undergoing cancer treatment.

Pre-operative atrial fibrillation and early right ventricular failure after left ventricular assist device implantation: a systematic review and meta-analysis.

BACKGROUND: Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD). Atrial fibrillation (AF) is known for its deleterious effects on cardiac function and hemodynamics. The association of pre-operative AF with the risk of early post-LVAD RVF has not been well described. METHOD: A comprehensive literature search was performed through April, 9 2021. Cohort studies comparing the risk of post-operative RVF and/or need for right ventricular assist device (RVAD) after LVAD in patients with or without AF were included. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic were calculated using the random-effects model. RESULTS: Six studies were included in the analysis. Post-operative RVF was reported in 5 studies (1,841 patients) and RVAD use was reported in 4 studies (1,355 patients). There is a non-significant trend toward a higher risk of post-operative RVF in the AF group (pooled OR=1.25, 95%CI=0.99-1.58). No significant association between AF and RVAD use is noted (pooled OR=1.17, 95%CI=0.82-1.66). CONCLUSIONS: Pre-operative AF is not significantly associated with higher risks of post-operative RVF and RVAD use after LVAD implantation, although the trend toward higher post-operative RVF is observed in patients with pre-operative AF. Additional research using a larger study population is warranted to better understand the association of pre-operative AF and the development of post-LVAD RVF.

Myocardial Abscess After Myocarditis: Advantages of Multimodal Imaging Detecting the Rare Case of Fungal Abscess.

We discuss the rare case of a myocardial abscess of the left ventricle in a 42-year-old man on immunosuppressive therapy after fulminant myocarditis. Multimodal imaging detected the myocardial abscess along with other septic emboli caused by infection with aspergillus fumigatus, which could be treated effectively with antimycotic strategies. (Level of Difficulty: Intermediate.).

Unintentional Implantation of a Permanent Pacemaker Lead Across a Patent Foramen Ovale Leading to Left Ventricular Pacing.

Unintentional placement of a left ventricular lead through a patent foramen ovale (PFO) is an uncommon and underdiagnosed complication. Normal single- or dual-chamber permanent pacemaker implantation involves placing a lead across the tricuspid valve into the right ventricle. In a very rare case instead of the lead going into the right ventricle, it goes through the PFO and across the mitral valve into the left ventricle (LV) resulting in LV pacing. We describe a case of one of our patients who presented with syncope due to bifascicular block and underwent a dual-chamber pacemaker implantation at a local hospital. He had a background of paroxysmal atrial fibrillation and sarcoidosis. Post-procedure, he was discharged with an inadvertent lead in the LV that was not identified. Abnormal placement of LV leads can result in serious complications including thromboembolism, mitral regurgitation, and left-sided endocarditis. Treatment options include extraction of the lead or anticoagulation.

Decoding Postinfarction Left Ventricular Pseudoaneurysm.

Recognizing true from pseudo left ventricular aneurysm after myocardial infarction is paramount to guide clinical management and determine need for surgical urgency. We discuss a case of a postinfarction pseudoaneurysm that poses unique anatomic challenges and may hold a secret "DaVinci code" beyond current diagnostic criteria. (Level of Difficulty: Advanced.).

Patent foramen Ovale-related paradoxical embolism after noncardiac surgery.

Patent foramen ovale (PFO) is a remnant of the fetal circulation that remains in a significant portion of the adult population, predisposing to a higher risk of stroke. This risk is further elevated in the postoperative hypercoagulative period. Here we present a case where a patient underwent a total knee arthroplasty and presented with right-sided hemiparesis on post-operative day 2. Subsequently, the patient underwent percutaneous PFO closure with a 25-mm Amplatzer PFO Occluder (Abbott; Chicago, IL, USA). The patient has not had a stroke since the PFO closure. Recent randomized trials have demonstrated superiority of percutaneous PFO closure over standard-of-care medical therapy for secondary prevention of PFO-associated stroke. Since post-operative PFO-associated stroke is under-recognized in clinical practice, further large-cohort studies are needed to evaluate whether PFO screening and device closure would decrease post-operative stroke risk for noncardiac surgeries. Learning Objective: Patent foramen ovale (PFO) is a remnant of the fetal circulation commonly found in the adult population, which can increase the risk of stroke. Stroke is a complication of PFO, yet closure of this remnant only occurs on a specific case-by-case basis. Further research in this area is required to determine whether a larger population would benefit from PFO closure.

High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways.

While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.

Right-to-left shunt via iatrogenic atrial septal defect requiring emergency surgical repair following cryoballoon atrial fibrillation ablation in a patient with arrhythmogenic right ventricular cardiomyopathy.

An 81-year-old woman with arrhythmogenic right ventricular cardiomyopathy underwent catheter ablation for atrial fibrillation and atrial flutter. Hypoxemia refractory to the administration of oxygen was seen after transseptal puncture. Transthoracic echocardiography revealed right to left shunt via an iatrogenic atrial septal defect (IASD) that was increased by tricuspid regurgitation flow. Her hypoxemia improved after IASD occlusion with the inflation of a venogram balloon catheter. Emergent surgical IASD closure was successfully performed. IASD after transseptal puncture for atrial fibrillation ablation infrequently causes severe complications that require emergent repair. Learning objective: Some cases requiring iatrogenic atrial septal defect (IASD) closure after atrial fibrillation (AF) ablation have been reported. We describe the case of an arrhythmogenic right ventricular cardiomyopathy patient with right to left shunt via an IASD which required emergent surgical repair after AF ablation. Right to left shunt after trans-septal puncture is rare, however it can be an emergent life-threatening complication. IASD occlusion with venogram balloon catheter is helpful for the diagnosis and the short-term solution.

Eosinophilic myocarditis: Case report and brief review of the literature.

Eosinophilic myocarditis (EM) is a cardiac manifestation of hypereosinophilic syndrome with a high mortality rate. EM shares imaging features similar to other restrictive cardiopathies, and include patchy intramural late gadolinium enhancement on cardiac magnetic resonance with or without presence of biventricular thrombus. Diagnosis is confirmed on histopathology, and is the current gold standard. Here we report clinical presentation and imaging findings of EM in a 70-year-old woman who presented with fever and chills.

Three-dimensional printing and virtual reconstruction in surgical planning of double-outlet right ventricle repair.

Objectives: For more than a decade, 3-dimensional (3D) printing has been identified as an innovative tool for the surgical planning of double-outlet right ventricle (DORV). Nevertheless, lack of evidence concerning its benefits encourages us to identify valuable criteria for future prospective trials. Methods: We conducted a retrospective study involving 10 patients with DORV operated between 2015 and 2019 in our center. During a preoperative multidisciplinary heart team meeting, we harvested surgical decisions following a 3-increment step process: (1) multimodal imaging; (2) 3D virtual valvular reconstruction (3DVVR); and (3) 3D-printed heart model (3DPHM). The primary outcome was the proportion of predicted surgical strategy following each of the 3 steps, compared with the institutional retrospective surgical strategy. The secondary outcome was the change of surgical strategy through 3D modalities compared with multimodal imaging. The incremental benefit of the 3DVVR and 3DPHM over multimodal imaging was then assessed. Results: The operative strategy was predicted in 5 cases after multimodal imaging, in 9 cases after 3DVVR, and the 10 cases after 3DPHM. Compared with multimodal imaging, 3DVVR modified the strategy for 4 cases. One case was correctly predicted only after 3DPHM inspection. Conclusions: 3DVVR and 3DPHM improved multimodal imaging in the surgical planning of patients with DORV. 3DVVR allowed a better appreciation of the relationships between great vessels, valves, and ventricular septal defects. 3DPHM offers a realistic preoperative view at patient scale and enhances the evaluation of outflow tract obstruction. Our retrospective study demonstrates benefits of preoperative 3D modalities and supports future prospective trials to assess their impact on postoperative outcomes.

Improved mid-term stability of MR reduction with an increased number of clips after percutaneous mitral valve repair in functional MR.

Background: Percutaneous mitral valve repair (PMVR) has evolved to be a standard procedure in suitable patients with mitral regurgitation (MR) not accessible for open surgery. Here, we analyzed the influence of the number and positioning of the clips implanted during the procedure on MR reduction analyzing also sub-collectives of functional and degenerative MR (DMR). Results: We included 410 patients with severe MR undergoing PMVR using the MitraClip® System. MR and reduction of MR were analyzed by TEE at the beginning and at the end of the PMVR procedure. To specify the clip localization, we sub-divided segment 2 into 3 sub-segments using the segmental classification of the mitral valve. Results: We found an enhanced reduction of MR predominantly in DMR patients who received more than one clip. Implantation of only one clip led to a higher MR reduction in patients with functional MR (FMR) in comparison to patients with DMR. No significant differences concerning pressure gradients could be observed in degenerative MR patients regardless of the number of clips implanted. A deterioration of half a grade of the achieved MR reduction was observed 6 months post-PMVR independent of the number of implanted clips with a better stability in FMR patients, who got 3 clips compared to patients with only one clip. Conclusions: In patients with FMR, after 6 months the reduction of MR was more stable with an increased number of implanted clips, which suggests that this specific patient collective may benefit from a higher number of clips.

Metformin effects on cardiac parameters in non-diabetic Iraqi patients with heart failure and mid-range ejection fraction - a comparative two-arm parallel clinical study.

Heart failure (HF) remains a difficult challenge to the healthcare system, necessitating promoting interventions and multidrug management. Metformin, typically used to manage diabetes, has emerged as a promising intervention in the treatment of HF. This study aimed to assess the effect of adding metformin to the standard treatment of HF on cardiac parameters. This clinical study comprised 60 newly diagnosed HF patients randomly assigned to two groups: Group C received standard HF treatment, while Group M received standard HF treatment in addition to daily metformin (500 mg). After 3 months of treatment, group M showed a significantly higher ejection fraction (EF) compared to Group C (6.1% and 3.2%, respectively; p-value=0.023) and a reduction in the left ventricular end-diastolic pressure (LVEDD) (0.28, and 0.21 mm respectively; p-value=0.029). No significant differences were observed in the interventricular septal thickness (IVST) or left ventricular end-systolic pressure (LVESD). For cardiac markers, N-Terminal pro-BNP (NT-proBNP) showed the highest reduction in Group M compared to Group C (719.9 pg/ml and 271.9 pg/ml respectively; p-value=0.009). No significant changes were reported for soluble ST2. Metformin demonstrated cardiac protective effects by increasing EF and reducing NT-proBNP. Given its affordability and accessibility, metformin offers a valuable addition to the current HF treatment options. This positive effect may be attributed to mechanisms that enhance the impact of conventional HF treatments or vice versa.

Acute Myocarditis: A New Manifestation of Monkeypox Infection?

A 31-year-old male patient with confirmed monkeypox infection developed acute myocarditis days after the eruption of skin lesions. Cardiac magnetic resonance study confirmed myocardial inflammation. The patient was treated with supportive care and had full clinical recovery. This case highlights cardiac involvement as a potential complication associated with monkeypox. (Level of Difficulty: Intermediate.).

Incremental Utility of 3D Printing to Guide the Surgical Management of Apical Aneurysm.

A 24-year-old man presented with a nonischemic cardiomyopathy of unknown etiology, apical aneurysm, and a secondary mitral regurgitation. Computer tomography-derived 3-dimensional model of the patient's heart was an essential step in guiding the surgical management for an optimal outcome. (Level of Difficulty: Advanced.).

From Double-Chambered Right Ventricle to Double-Chambered Left Ventricle: Unusual Evolution of a Ventricular Septal Defect.

We present the first imaging registry of the progressive isolation of an apical chamber of the right ventricle caused by the hypertrophy of the moderator band generated from the hemodynamic effect of a ventricular septal defect, leaving the apex of the right ventricle as an accessory chamber of the left ventricle. (Level of Difficulty: Advanced.).

EUS-guided biopsy of an intraventricular mass in a patient with ventricular tachycardia.

Video 1Endoscopic ultrasound-guided fine-needle biopsy of an intraventricular mass in a patient with ventricular tachycardia.

Swimming-Induced Pulmonary Edema: An Underrecognized Cause of Triathlon-Associated Medical Emergencies.

Swimming-induced pulmonary edema is a leading cause of triathlon-associated emergencies and death. Cold water immersion, female sex, age>50, and wetsuit compression are associated risk factors. Pathophysiology is due to increased central blood pooling, leading to increased pulmonary capillary wedge pressure. Treatment is focused on prevention; however, recurrence is common. (Level of Difficulty: Intermediate.).

Giant Localized Atheroma Mimicking a Coarctation of the Aorta: A Rare Entity to Consider.

We describe the case of a patient who developed resistant hypertension due to a giant atheroma with acquired physiologic mimic of coarctation of the aorta. This presentation illustrates an extremely rare etiology to consider in adults in whom aortic isthmus stenosis remains often of congenital origin. (Level of Difficulty: Intermediate.).

Subclinical Hypertrophic Cardiomyopathy in Elite Athletes: Knowledge Gaps Persist.

Subclinical hypertrophic cardiomyopathy (HCM) is a phenotypic entity that has emerged from the increased use of cardiovascular magnetic resonance imaging in the evaluation and family screening of patients with HCM. We describe the case of a competitive athlete with a sarcomere gene mutation and family history of HCM who was found to exhibit the subclinical HCM phenotype on cardiovascular magnetic resonance imaging in the absence of left ventricular hypertrophy. We discuss the clinical uncertainties in her management. (Level of Difficulty: Advanced.).

Pragmatic assessment of resident performed cardiac point of care ultrasound using a validated scoring metric.

Background: Cardiac point of care ultrasound (POCUS) is increasingly utilized by trainees across various specialties and can rapidly assess the cardiac status of unstable patients. However, the quality of trainee performed cardiac examinations has been reported only in controlled studies. In this study we aimed to assess the quality of all cardiac POCUS performed by internal medicine trainees at a major academic medical center over a three-year period. Methods: 256 studies were included and were graded by experts blinded to postgraduate year (PGY) using a previously validated scoring metric. Results: We found significant improvement in overall quality of resident performed cardiac POCUS from PGY 1 to 3 (10.8, 10.2, 13.2, p = 0.012). Assessment of left ventricular function was possible in 82% of studies and increased from PGY 1 to PGY 3 (77%, 76%, 88%, p = 0.025). Similar trends were seen in the assessment of the pericardial space (67%, 71%, 84%, p = 0.012). Images sufficient for right ventricular and volume status assessment were less commonly found (65%, 60%, 75% and 60%, 49%, 57%, respectively). Conclusions: This study provides a real world experience of the level of diagnostic accuracy that can be expected from IM trainees with minimal hands-on supervision.