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Background: COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation. Purpose(s): To study the impact of COVID-19 in a adult patients with CHD Methods: Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records. Result(s): We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease;seven Tetralogy of Fallot;five (6%) transposition of great arteries;eight (10%) right ventricle obstacle;two (3%) atrioventricular canal defect;sixteen (20%) atrial septal defect;nine (11%) ventricular septal defect;eight (10%) aortic coarctation;two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02). Conclusion(s): Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome;the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.
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Background: Adults with congenital heart disease (ACHD) are considered at increased risk for complications due to COVID-19, especially in those with cyanosis or heart failure. However, data regarding the rate of infection as well as regarding a myocardial involvement of a COVID-19 infection in ACHD patients are currently lacking. Purpose(s): To study the rate of COVID-19 infections in ACHD patients from a tertiary centre as well as the rate of myocardial involvement of a COVID- 19 infection. Method(s): All consecutive ACHD patients (over the age of 18 years) who attended the outpatient clinic of a tertiary centre from January 2021 to June 2021 were eligible to participate. Demographic data, as well as medical/ surgical data including a history of a COVID-19 infection were collected. All patients had an antibody test for COVID-19. Patients with a positive antibody test were offered cardiovascular magnetic resonance imaging (CMR). Result(s): Altogether, 420 patients (44.8% female, mean age 36.4+/-11.6 years) were included in the study. Congenital heart defect (CHD) complexity according to the Bethesda classification was simple in 96 (22.9%), moderate in 186 (44.3%), complex in 117 (27.9%), and miscellaneous in 21 (5.0%) patients. A positive antibody test for COVID-19 was present in 28 (6.7%) patients (CHD complexity: Simple n=5, moderate n=14, severe n=7, miscellaneous n=2). Out of these 28 patients, 14 had no symptoms at all. Those with symptoms had mainly mild symptoms and were all managed in the outpatient setting. While 11 patients (39.3%) were not at all aware of their infection, 17 already knew that they had COVID-19. There was no significant difference between ACHD patients with a positive test vs those with a negative test regarding age, gender, New York Heart Association class, or complexity of CHD. Out of the 28 patients with a positive antibody test, 14 agreed to a CMR. A myocardial involvement, i.e. signs of active or healed myocarditis, was not present in any of these. Conclusion(s): In this single-centre study, 6.7% of ACHD patients attending the outpatient clinic had positive antibodies for COVID-19. Out of these, 50% were asymptomatic and 39.3% were not aware of their infection. A myocardial involvement was not found in any of the patients that underwent a CMR. These results indicate a large number of undetected cases of COVID-19 in the ACHD population and offer reassurance that in the vast majority of cases the infection has a mild course.
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Background: Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. Case presentation: A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Conclusion(s): Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain;however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.Copyright © 2022
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Background: mRNA-based COVID-19 vaccines have been reported to rarely cause myocarditis. Although myocardial biopsy is considered gold standard in the diagnosis of myocarditis, no standardized study following COVID-19 vaccination in humans was performed so far. Since heart transplant (HTX) recipients frequently undergo routine myocardial biopsy, we here aimed to investigate effects of COVID-19 vaccination by analyzing myocardial inflammation by state-of-the-art quantitative immunohistochemistry. Method(s): Consecutive patients after HTX who underwent routine endomyocardial biopsies at a median of 167 days before and 136 days after their first COVID-19 vaccination with a mRNA vaccine were included and divided into groups with and without inflammatory response following vaccination, defined as increased number of CD3+ lymphocytes >14/mm2. Patients with histological signs of rejection (ISHLT Grade >1) or >14 CD3+ lymphocytes/mm2 at baseline were excluded. Afterward clinical characteristics of patients with inflammatory response were screened for signs of myocarditis. Result(s): The final analysis included 46 patients with a median age of 63 years and a time post-HTX of 2.4 years. Immunosuppressive therapy remained unchanged between biopsies. 36 (78%) patients remained below the cut-off of 14 CD3+ lymphocytes/mm2. However, in 10 (22%) recipients, we detected significant leucocyte infiltration by quantitative analysis of endomyocardial biopsies following vaccination (4 vs. 33.7 leucocytes/mm2, p = 0.001). Groups did not differ in age (63 vs. 57 years, p = 0.21), body mass index (25 vs. 24 kg/m2, p = 0.24), NYHA-class (>=2 in 19 vs. 10%, p = 0.4), NTProBNP levels (592 vs. 514 ng/L, p = 0.55) or myocardial CD3+ cell count (4.9 vs. 2.6 cells/mm2, p = 0.07) before vaccination. Patients with leucocyte infiltration remained clinical inapparent with stable NYHA class (>=2 in 10 vs. 20%, p = 0.99) and depicted no increased NT-ProBNP levels (514 vs. 478 ng/L, p = 0.03). No hospitalizations due to suspected myocarditis were reported. Conclusion(s): For the first time, we report subclinical myocardial leucocyte infiltration following COVID-19 mRNA vaccination in every fifth patients without clinical consequences during the short observation period.
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Objectives: To study the clinico-electrophysiological profile of patients with Infrahisian Wenckebach (IHW) conduction. Material(s) and Method(s): Patients with a clinical diagnosis of atrioventricular (AV) block who underwent permanent pacemaker implantation (PPI) based on standard indications from July 2021-June 2022 at The Madras Medical Mission were subjected to pre-implant Electrophysiology study to document conduction pathology. Result(s): A total of 94 patients underwent PPI for AV block during the study period. EPS was performed in all but one patient (COVID pneumonia). The incidence of IHW was 9/93 (9.6%) of patients with AV block. There is no gender predisposition (M-4, F-5) and their mean age was 71.4 +/- 11.7 years. As many as half of the patients (5/9) had an underlying narrow QRS. The mean QRS duration was 130 +/- 19.3. Ischemic heart disease affected half of the patients and cardiomyopathy in 4/9 patients (mean EF 45.1 +/- 13.7%). Presentation was syncope in all, mean NYHA class was 2.1. Presentation ranged from isolated 1st-degree AV block (1/9) to tri-fascicular block (3/9). In EP study, the mean basal HV interval was 94.7 +/- 27.1 ms. IHW was noted spontaneously in 4 patients and on atrial pacing in the remaining. In the literature, a total of 11 documented cases have been reported (8 case reports). Unlike typical Wenckebach, the increment in PRI is minimal in the 2nd beat of the train. Conclusion(s): Wenckebach periodicity is classically considered an AV nodal phenomenon. IHW is scarcely reported in the literature. Distinction becomes critical as IHW is harbinger of a complete AV block. This is the largest series and the first clinic-etiological profile of IHW patients published to date.
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Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.
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Background: Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran. Method(s): Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17+/-1.75 years. Result(s): All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25+/-2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08+/-1.98 mm Hg to 5.29+/-1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00+/-49.46 ms to 158.64+/-57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91+/-7.31 mm Hg to 26.72+/-8.99 mm Hg, and left ventricular ejection fraction increased from 47.71+/-4.70% to 49.79+/-4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up. Conclusion(s): This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results. Copyright © 2022 Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.
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Background: Treatment of symptomatic mitral valve stenosis in severe mitral annular calcification is a surgical challenge. Transcatheter options include transfemoral transcatheter mitral valve replacement (TMVR), which poses its own risks, the most significant is left ventricular outflow tract (LVOT) obstruction. Transatrial hybrid TMVR optimizes advantages of both traditional open-heart surgery and transcatheter valve replacement. Methods: Retrospective review of seven high-risk patients (deemed ineligible for traditional surgery) undergoing transatrial implantation of a SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA) in the mitral position for severe symptomatic mitral stenosis. Laceration of the Anterior Mitral leaflets to Prevent Outflow ObstructioN procedure was not considered due to heavy leaflet calcifications. Results: Seven patients treated consecutively from June 2020 to July 2021 were included in this analysis. Mean age was 77 years;six were females, one was male. Average STS score was 9.8. Three patients had New York Heart Association (NYHA) class IV heart failure. Mean left ventricular ejection fraction was 62%. Dominant mitral valve pathology included mitral stenosis in all patients. Mean mitral valve gradient was 12 mmHg. All patients had circumferential annular calcification except one, who had predominantly anterior calcification. All patients received the Edwards SAPIEN 3 valve and had anterior leaflet resection. Surgical approach was at the discretion of the attending cardiac surgeon. Mean cardiopulmonary bypass time was 85 minutes;mean cross-clamp time was 36 minutes. No anchoring felt was used. Technical success was 100%, with no device embolization. There was no clinically significant LVOT obstruction. There were two deaths: one occurred during index hospitalization due to worsening heart failure secondary to torrential tricuspid regurgitation, and the second was 2 months later due to COVID-19 infection. Conclusion: Surgical hybrid transatrial TMVR for patients at high surgical risk is technically feasible with high procedure success. A relatively shorter cardiac ischemic duration, direct visualization and resection of the anterior mitral leaflet can allow for safe TMVR without risk of LVOT obstruction.
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Background: Advanced heart failure (HF) is a complex clinical syndrome with scarce therapeutic options. Despite growing body of research in the field, no alternative end-stage solution is available for those individuals who are not eligible for heart transplant and mechanical circulatory support. The efficacy of implantable hemodynamic monitoring is currently being tested. Clinical manifestations of congestive HF appear late in the progression to acute decompensation, whereas intracardiac pressures rise gradually and can anticipate, even by weeks, the symptoms onset, thus offering a sweet spot to timely face an incipient acute decompensation. To date, the only implantable monitoring systems which received the regulatory agencies approval is a PAP sensor allowing PAP-guided management in symptomatic patients with reduced left ventricular ejection fraction (LVEF <35%). Although right-sided pressures data have proved their usefulness, they do not always correlate with left heart chambers pressures, so that PAP indirect estimation of left ventricular filling pressure can be misleading in some clinical contexts. Purpose. The V-LAP system is the latest-generation device, capable of monitoring the left atrial pressure (LAP) directly, by an intracardiac leadless sensor, transmitting LAP data wirelessly to an external reader. It is designed to offer a continuously updated status of the left-sided hemodynamics in order to improve the outcomes of advanced chronic HF-patient by reducing HF-related hospitalizations. Methods: In our center, V-LAP was implanted in five NYHA class III HF patients, not eligible for heart transplant, with a history of frequent hospital readmission and recurrently elevated proBNP levels. After confirmation of the device reliability, LAP trends have been remotely monitored over time in order to guide therapy optimization. Results: Over a median follow-up time of 18 months, LAP - driven therapy adjustments succeeded in noticeably reducing LAP and no HF-related hospitalization occurred in all patients considered. Morover, functional capacity improved in three out of five patients (NYHA class from III to II), and this was paralleled by an increase in the perceived quality of life as indicated by the KCCQ summary score (67.01±15.95 at baseline vs 83.21±11.94 at latest follow-up). The overall compliance of our patients to daily LAP measurements was > 90%, attesting a remarkable patient usability and acceptance. Conclusion: Preliminary data from V-LAP application at our institution expressed optimistic efficacy, along with remarkable reliability and ease of use, encouraging patients to adhere with a high compliance rate. In covid-19 era, VLAP revealed to be an excellent tool to control HF patients avoiding medical contacts and in-hospital exposure. While further study is needed, heart failure patient management guided by the V-LAP system may have the potential to significantly improve clinical outcomes.
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Coronary artery disease (CAD) is widely considered a chronic inflammatory disorder, and dysfunction of epicardial adipose tissue could be an important source of the inflammation. Amino-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) is a known marker of cardiovascular disorders of cardiac origin. Recent studies show that inflammatory stimuli may influence its secretion. Our purpose was to evaluate NT-proBNP serum concentration in relation to immune cell ratios in epicardial adipose tissue (EAT), and cytokine levels in the patients with stable CAD. Patients with stable CAD and heart failure classified into classes II-III, according to the New York Heart Association (NYHA) scale, scheduled for the coronary artery bypass graft (CABG) surgery, were recruited into the study (n = 10;59.5 (53.0-65.0) y. o.;50% males). The EAT and subcutaneous adipose tissue (SAT) specimens were harvested in the course of CABG surgery. Immunostaining with anti-CD68, anti-CD45, anti-IL-1β and anti-TNFα monoclonal antibodies was performed to evaluate cell composition by differential counts per ten fields (400 magnification). Fasting venous blood was obtained from patients before CABG. Blood was centrifuged at 1500g, aliquots were collected and stored frozen at -40 °С until final analysis. Concentrations of NT-proBNP, IL-1β, IL-6, IL-10, TNFα were determined in serum samples by enzyme-linked immunosorbent assay (ELISA). We have found increased production of IL-1β and TNFα cytokines in EAT compared to SAT. Concentrations of NT-proBNP exceeded 125 pg/ml in 4 patients, and correlations between the CD68+ macrophage counts in both EAT and SAT samples (rs = 0.762;p = 0.010 and rs = 0.835;p = 0.003, respectively). NT-proBNP levels showed positive relations with CD45+ leukocyte counts (rs = 0.799;p = 0.006), and with IL-1β+ cell numbers (rs = 0.705;p = 0.023) in EAT samples only. As for the serum biomarkers, NT-proBNP levels showed negative correlation with fasting glucose levels (rs = -0.684;p = 0.029), and positive correlation with serum IL-6 concentrations (rs = 0.891;p = 0.001). Increased serum concentrations of NT-proBNP in CAD patients correlate with accumulation of macrophages in EAT, which is associated with increased production of IL-1β in EAT and correlates with some metabolic parameters.
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RATIONALE: Pulmonary arterial hypertension (PAH) is a rare, progressive disease leading to right ventricular failure and premature death. The functional limitation and survival of patients with PAH remains unsatisfactory. Ralinepag, an orally available, potent, and selective, nonprostanoid, prostacyclin receptor agonist, is a new chemical entity in development to treat PAH. METHODS: The ADVANCE OUTCOMES (NCT03626688) study is a randomized, double-blind, placebocontrolled, event-driven study evaluating the efficacy and safety of ralinepag in subjects with PAH. In this event-driven, Phase 3 study, approximately 700 subjects with PAH treated with standard of care are randomly assigned (1:1) to receive ralinepag or placebo. Dosing is individualized and titrated based on tolerability and clinical response. The primary objective is to assess the effect of ralinepag on the time to first adjudicated clinical worsening event;a composite endpoint including death, hospitalization due to worsening of PAH, initiation of inhaled or infused prostacyclins, disease progression, or unsatisfactory long-term response. Additional secondary assessments during the study include changes from Baseline to Week 28 in N-terminal pro-brain natriuretic peptide (NT-proBNP), 6-minute walk distance (6MWD), WHO/New York Heart Association (NYHA) Functional Class, and health-related quality of life measures. Exploratory assessments will evaluate biomarkers and pharmacogenetics. Subject safety is evaluated by capturing adverse events, hospitalizations, clinical laboratory, and ECG parameters. Subjects who experience a clinical worsening event or are participating at study closure are eligible to enter an open-label extension study (ROR-PH-303 [NCT03683186]). Long-term survival will be followed for all subjects until study closure. RESULTS: Enrollment is ongoing at approximately 200 sites in 33 countries following implementation of risk mitigation steps related to the Covid-19 pandemic. Enrollment will continue until 228 adjudicated clinical worsening events have occurred. The interim assessment includes 281 subjects randomized in 29 different countries;97% of participants have completed 28 weeks of treatment. The majority of subjects were female (79.4%) with a median age of 48.0 years, were receiving dual background therapy (82.9%), and were classified as Functional Class II (59.3%). Overall, 48 clinical worsening events have been reported at the time of the interim assessment. Of these, 34 subjects elected to continue treatment in the open-label extension study. An independent Data Monitoring Committee reviewed safety data after 50, 100, and 250 subjects were randomized and recommended study continuation without modification. CONCLUSIONS: ADVANCE OUTCOMES will assess whether ralinepag can improve function, delay disease progression, and prolong survival in subjects with PAH.
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A 76 year old woman was admitted to our hospital for self-limiting dyspnoea (NYHA class III) in oxygen dependence and frequent lipothymia following Valsalva manoeuvres. She was previously admitted to a Spoke Centre for heart failure (HF) with preserved ejection fraction (EF) and a new diagnosis of “pre-capillary pulmonary hypertension (PH)”. Despite a diagnosis of PH of unclear aetiology, she was started on macitentan without being reassessed for functional capacity due to Covid emergency;because of worsening symptoms, she was admitted to our Hub Centre. Resting ECG showed right axis deviation, right ventricle (RV) hypertrophy, first-degree atrioventricular block and right bundle branch block. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) volume with preserved EF (diastolic volume= 37 ml, EF=88%), severe right atrial and RV dilation with flattening of the interventricular septum, estimated pulmonary artery systolic pressure (PASP) of 124 mmHg, and moderate calcific aortic stenosis (peak aortic velocity 3.3 m/s, mean gradient 25 mmHg, valve area 1.1 cm2). Right and left heart catheterization showed severe pre-capillary PH (mean pulmonary pressure 60 mmHg, mean wedge 11 mmHg, pulmonary vascular resistance 14.41 WU), a severe aortic valve stenosis (aortic valve area 0.68 cmq and peak-to-peak gradient 25 mmHg, slight reduction of cardiac index 2.04 l/min/mq) and no significant coronary artery disease. The degree of aortic stenosis was considered as moderate-severe by integrating data of transesophageal echocardiography (planimetric area 1cm2) and assessment of calcium score (1615 Agatson units). Pneumological causes, chronic thromboembolic PH, rheumatologic diseases, HIV infection, paraneoplastic origin and veno-occlusive disease were all ruled out as potential PH causes and a diagnosis of Idiopathic pulmonary arterial hypertension (IPAH) was finally made. The Heart Team established the best therapeutic option was a transcatheter aortic valve replacement (TAVI) allowing better haemodynamic tolerability of PH therapy. The patient underwent TAVI and was started on PH therapy;a complete atrio-ventricular block developed after the procedure, requiring permanent pacemaker (PM) implantation. Unfortunately, few days later, the patient died following pacemaker's lead dislocation. Conclusion: PH has a diverse aetiology, and prognosis is generally poor, especially in patients with severe comorbidities. (Figure Presented).
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Myxoma (mx) is the most frequent adult cardiac tumour, that often poses a difficult diagnostic challenge due to the variety and aspecifity of presenting clinical signs. Alongside the more typical clinical onset caused by intracardiac obstruction and systemic embolization, mainly at cerebral level, a mx may initially manifest itself with nonspecific systemic symptoms such as fever, weight loss, fatigue, skin rash, myalgia and arthralgia. We present the case of a 58-year-old woman diagnosed in December 2018 with idiopathic, serum-negative arthritis of the metacarpophalangeal joint of the first finger of the right hand, treated with methotrexate (Reumaflex 10 mg/week s.c.), hydroxychloroquine sulphate (Paquenil 200 mg/day per os) and corticosteroids cycles;in January 2021, this therapy was suspended by the patient (pt) as ineffective. In April 2021, pt was admitted for bilateral SARS-CoV-2 pneumonia. As dyspnoea and fatigue persisted during moderate physical activity (NYHA class II), the pt underwent a cardiological examination on 13 August, when echocardiographic diagnosis of a left atrial mass with the appearance of a mx was made. Interleukin-6 (IL-6) was assayed for a suspected relationship between the cardiac tumour and rheumatic symptoms and was found to be elevated (490 pg/m)l. On 23 August, cardiac surgery was performed to remove the left atrial mass by right minithoracotomy. Histopathological examination confirmed that the 3.5 x 2.5 x 1.5 cm neoformation was a mx. On 1 September, strong attenuation of joint pain and IL-6 reduction to 107 pg/ml was detected. On 9 October, resolution of rheumatic symptoms and normalisation of IL-6 to 3.7 pg/ml (N.V < 7) occurred. This clinical case is emblematic of the long time that sometimes can elapse between the first clinical manifestation and the diagnosis of mx. Also the widespread use of echocardiography did not significantly reduce the diagnostic delay when cardiac symptoms are absent. In a large number of cases, onset symptoms mimicking autoimmune connective tissue disease are reported for 5% (“Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases” Medicine (Baltimore) 2001 May;80(3):159-729). The monoarticular localisation we describe is however unusual. Finally, our observation confirms that the association between mx and systemic symptoms is most likely due to IL-6 synthesis by tumour cells. (Figure Presented).
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Aim. To study the survival of patients with New York Heart Association (NYHA) class IIIV heart failure (HF) after a coronavirus disease 2019 (COVID-19) and compare it with a group of similar patients without COVID-19, both during and before the pandemic. Material and methods. A sample of 810 patients with HF of any class was created, who were treated in the HF center at the City Clinical Hospital N 38 in Nizhny Novgorod for the period from March 2019 to March 2020. Patients with NYHA class HF III-IV (n=263) were selected from this sample. The diagnosis was confirmed by echocardiography and chest radiography. At the time of discharge, the 6-minute walk test was <300 meters, while the level of N-terminal pro-brain natriuretic peptide — >300 pg/ml. The group was analyzed from March 2019 to December 2021 with the definition of all-cause mortality depending on prior COVID-19. Results. During 520-day follow-up, 30,8% of NYHA class III-IV patients died, while 16,0% of patients underwent COVID-19, of which 79,25% of patients died during this period. Mortality among patients without prior COVID-19 was 23,3% (p<0,001). The 30-day mortality among those with COVID-19 was 50,0%, while for the year, this parameter was 71,4% (p<0,001). Among patients without COVID-19 and with class III-IV HF, 4,64% died in the first 30 days, and 20,7% of patients died during the year (p<0,001). The results obtained were compared with the data from the EPOCHA-CHF program from 2002 to 2017. Conclusion. Mortality among patients with class III-IV HF after COVID-19 was 3,5 times higher compared with those with class III-IV HF without prior COVID-19. During the COVID-19 pandemic, the mortality rate among patients with class III-IV HF without COVID-19 increased by 2,09 times compared with the pre-pandemic period.
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In hospitalized COVID-19 patients, myocardial injury and echocardiographic abnormalities have been described. The present study investigates cardiac function in COVID-19 patients 6 weeks post-discharge and evaluates its relation to New York Heart Association (NYHA) class. Furthermore cardiac function post-discharge between the first and second wave COVID-19 patients was compared. We evaluated 146 patients at the outpatient clinic of the Leiden University Medical Centre. NYHA class of II or higher was reported by 53% of patients. Transthoracic echocardiography was used to assess cardiac function. Overall, in 27% of patients reduced left ventricular (LV) ejection fraction was observed and in 29% of patients LV global longitudinal strain was impaired (> − 16%). However no differences were observed in these parameters reflecting LV function between the first and second wave patients. Right ventricular (RV) dysfunction as assessed by tricuspid annular systolic planar excursion (< 17 mm) was present in 14% of patients, this was also not different between the first and second wave patients (15% vs. 12%;p = 0.63);similar results were found for RV fraction area change and RV strain. Reduced LV and RV function were not associated with NYHA class. In COVID-19 patients at 6 weeks post-discharge, mild abnormalities in cardiac function were found. However these were not related to NYHA class and there was no difference in cardiac function between the first and second wave patients. Long term symptoms post-COVID might therefore not be explained by mildly abnormal cardiac function.
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Introduction: Inflammatory cardiomyopathies can be a diagnostic dilemma. Early management can lead to reduced morbidity and mortality for patients. We describe a rare presentation of an unusual cardiomyopathy. Case Report: A 58-year-old female presented with a 10-day prodrome of cough, NYHA class III dyspnea, and fatigue with minimal symptoms of orthopnea, paroxysmal nocturnal dyspnea or peripheral edema. She was previously healthy with no cardiac medications. Family history was significant for granulomatosis with polyangiitis. COVID-19 swab was negative. She was symptomatic with transient complete heart block and junctional escape of 20bpm. A temporary transvenous pacemaker was placed. Echocardiogram showed biventricular dysfunction with left ventricular ejection fraction < 30%. Troponin and brain-natriuretic peptide were elevated. Coronary angiogram showed no significant occlusions. CT excluded pulmonary embolism, pneumonia, or adenopathy. She was initiated on heart failure medications but beta blocker was not started given heart block. Six days into admission, her heart failure improved but she developed transient complete heart block without junctional escape. There was no ventricular ectopy. Evaluation for rheumatologic, infectious, and inflammatory causes showed elevated C-reactive protein and antineutrophil cytoplasmic antibodies. The remainder of the workup was negative. Leading diagnoses were idiopathic giant cell myocarditis or cardiac sarcoidosis. An endomyocardial biopsy revealed multinucleated giant cells and myocyte necrosis. She was diagnosed with giant cell myocarditis. Prior to discharge, she had defibrillator insertion and was initiated on prednisone and tacrolimus. Shortly after this time, she returned with critical cardiogenic shock despite intensification of immunosuppressive therapies and was listed for cardiac transplant. Giant cell myocarditis (GCM) is a rare and often fatal autoimmune cause of heart failure. Patients frequently present with congestive heart failure, ventricular arrhythmia and a rapid progression of symptoms. In GCM, it is rare to present with atrioventricular conduction delays. Given the crossover in symptoms with sarcoidosis and GCM, diagnosis may be challenging. In this case of an acute presentation of heart failure and complete heart block, endomyocardial biopsy was central to the diagnosis and management of GCM.
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Objective- The aim of this study was to assess whether major blood inflammatory parameters like neutrophil/lymphocyte ratio (NLR), interleukin-6 (IL-6) and high sensitivity C-reactive protein (hs-CRP) levels are associated with left ventricular remodeling parameters, New York heart association (NYHA) functional classes and pro-B- type natriuretic peptide (pro-BNP) levels in patients with idiopathic DCM. Methodology-59 patients with DCM were initially screened and categorized as idiopathic DCM and 22 were included for further analyses due to COVID-19 restrictions and positive cases were eliminated from the study. Biochemical assessment and echocardiographic investigations were done to assess cardiac structure and function. Results- There was a statistically significant correlation found between NLR and NYHA functional class (r=0.48, p<0.001), pro-BNP level (r=0.61, P<0.001) and left ventricular (LV) systolic parameters. Similar correlation was observed for IL-6 (with NYHA, r=0.40, P=0.011 and with pro-BNP, r=0.55, P=0.002). hs-CRP showed low to moderate correlation with the cardiac markers. NLR was also significantly higher in NYHA functional class III-IV patients (n=11) compared to NYHA class I-II (n=11), (3.1±0.5 vs 3.8±0.8, P=0.045). IL-6 showed similar significant difference between NYHA class I-II and III-IV (10.0±2.6 vs 20.0±11.2, P=0.045). NLR and IL-6 also found to be independent positive predictors of heart failure progression in NYHA class III-IV (P=0.019 and 0.015 respectively). Conclusion- Our findings clearly exhibit the efficacy of NLR and IL-6 in predicting severity of chronic heart failure in IDCM patients.
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Objectives: This study is a randomized clinical trial aimed to investigate the effects of a home-based cardiac rehabilitation exercise program with social media-based supervision on NT-proBNP level and functional capacity of heart failure with reduced ejection fraction patients. Methods: We randomly recruited 25 subjects with left ventricle ejection fraction <40%, early after heart failure hospitalisation, resting heart rate <100 bpm, NYHA class I and II, and 6MWT entry test >100 m. Subjects were allocated into combination of hospital and home group (Control Group/CG) (n=12) and the home group under supervision of videocall telemonitor using WhatsApp (Intervention Group/IG) (n=13). Both groups got an exercise program 5 times / week, moderate intensity, 30 minutes per session for 4 weeks. The endpoint is a change in NTproBNP level and 6 minute walk distance (6MWD) at week 4 as a marker of increased functional capacity. Results: The groups have similar baseline characteristics. There was a significant decrease in NT-proBNP levels in IG and CG (2834±1546.39 pg/ mL and 3340±853.18 pg/mL, p=0.001 vs 0.041). Comparative analysis of changes in NT-proBNP level between the two groups did not show a significant difference (p=0.979). Post-intervention NT-proBNP levels in the IG group were 2553±778.86 pg/mL and CG group 2448.90±701.84 pg/mL, p=0.852. The 6MWT distance increased significantly in both groups (IG and CG 29.92±30.95 m vs 69.75±75.68 m, p=0.005 vs 0.009, respectively), mean increase in CG was higher than IG, but not significant (p=0.225). Postintervention 6MWD result of the IG was 340.92±109.38 m, and CG 378.42± 142.69 m, p=0.401. Conclusion: Home-based telemonitored cardiac rehabilitation with social media supervision (using WhatsApp) programs has comparable effectiveness as the combined cardiac rehabilitation program. In current COVID-19 pandemic, home-based telemonitored cardiac rehabilitation program can be implemented with similar benefit as conventional program.
ABSTRACT
Background: Cardiovascular diseases have been identified as major risk factors for adverse outcomes in patients with novel coronavirus 2019 disease (COVID-19). Patients with genetic diseases of the heart, including those with hypertrophic cardiomyopathy (HCM), have been warned regarding higher risk of adverse outcomes following COVID-19. No specific data, however, has been reported regarding the actual risk of COVID-19 in adults with HCM. We aimed to evaluate incidence and outcomes of COVID-19 in a cohort of adults with HCM followed at one center. Methods: Adults with phenotypic HCM [n=199, age 57±17 years, 55% men, 22% New York Heart Association class >1, 57% obstructive, 9% septal reduction therapy, 22 % positive family history, 41% selectively genotyped (40% positive for pathogenic mutations in MYBPC3, MYH7, and TNNI3 genes), 24% cardioverter-defibrillator implants, 24% paroxysmal or permanent atrial fibrillation (AF), 7% AF ablation] were retrospectively evaluated. Results: Overall, 14 (7%) were diagnosed with COVID-19 [50% men, age 56±16 years, 57% obstructive HCM, 21 % positive family history, 7% genotype positive]. There was no statistically significant demographic or clinical differences between 14 with and 185 without [56% men, age 58±17 years, 57% obstructive, 22 % positive family history, 17% genotype positive] COVID-19 Among those with COVID-19, 4 (27%) were hospitalized and 1 (7%) died of COVID-19. Compared to those with mild disease, hospitalized patients with COVID-19 were older (age 63±13 vs. 53±16 years), more often men (75% vs. 40%) and more often had a positive family history of HCM (50% vs. 10%) without significant differences in other demographic or clinical features. Only 1 patient (7%) was fully vaccinated prior to COVID-19 and had mild symptoms. Currently, 104 (52%) have received at least one dose of a COVID-19 vaccine and 83 (42%) are fully vaccinated. Conclusions: Although COVID-19 infection rate (7%) in this cohort of patients with HCM was below the rate in the general US population (∼10%), hospitalization rate (27%) and death rate (7%) were above those noted in the nation (6.7% and 1.8%, respectively). The data confirms the notion that patients with HCM may have higher risk for developing COVID-19 related adverse outcomes.
ABSTRACT
Background: COVID-19 is the highly contagious infectious disease, which affects different organs and systems. Anxiety and depression symptoms, that are common results of severe diseases, used to make recovery more difficult. Purpose: To study the prevalence of cardiovascular diseases, signs of anxiety, depression, stress, and their relationship in patients with proven COVID-19 pneumonia 3 months after discharge depending of gender. Methods: The study was carried out within “One-year Cardiac Follow-up of COVID-19 Pneumonia”. 103 patients (mean age 46.6±15.8 years) were divided into 2 groups: 52 men (50.9%) and 51 women. Anxiety and depression symptoms were measured by GAD-7 and PHQ-9, respectively. PSS-10 was used to measure stress symptoms. The minimum value of anxiety and depression was a total value of 5 points. Results: 48.5% of patients had cardiovascular diseases, out of which arterial hypertension (AH) was the most common (44.7%). Less common was coronary artery disease (CAD) (16.5%), which in 14.6% of patients was accompanied by AH. Chronic heart failure (CHF) NYHA class I-II was found in 19.4% of patients, and severe CHF (NYHA class III-IV) - in 4.9%. Arrhythmia was detected in 11.7% of patients. According to the clinical characteristics, no significant differences were found between the groups of men and women. AH affected 21.4% of men and 23.3% of women, CAD -10.7% and 5.8%, respectively. NYHA class I-II CHF were found in 8.7% of men and 10.7% of women, and severe CHF (NYHA class III-IV) - in 2 men and 3 women. Arrhythmia had a prevalence of less than 6% among both men and women. Anxiety or depression symptoms were reported in 29.1% and 27.2%, respectively. Combination of anxiety and depression symptoms was determined in 18.4%, symptoms of stress in 8.7% of patients. Symptoms of depression were found in women more often (p=0.023). The value of the median scores of the PHQ-9 questionnaire in the group of women was significantly higher than in the group of men (3.00 [1.00;8.00] and 1.00 [0;3.75], p=0.006). Depression symptoms were associated with female gender (OR 2.83;CI 95% 1.35-7.08). Despite the absence of gender differences in the prevalence of anxiety (18.4% and 10.7%, p=0.072), when comparing the values of the median scores of the GAD-7 questionnaire in the groups of men and women, the difference was statistically significant (1.00 [0;4.00] and 3.00 [2.00;7.00], p=0.001, respectively). Signs of stress among married people were less common in comparison with unmarried (2.9% vs 5.8%, p=0.037). Conclusion: Three months after discharge, no significant differences in clinical characteristics between men and women were found. Signs of anxiety or depression were detected in more than a quarter of patients with proven COVID-19-associated pneumonia. Women experienced symptoms of depression 3 times more often than men. Unmarried patients tended to experience stress more often.