Recurrent Embolic Strokes in a Young Patient - a Case of Late Tavr Thrombosis and Endocarditis

Background Late complications of transcatheter aortic valve replacement (TAVR) are uncommon. We present a patient two-years post TAVR with recurrent strokes. Case A 56-year-old male with history of TAVR and pacemaker first presented with left-sided weakness found to have acute right MCA strokes and COVID. TTE showed a non-thickened valve with normal gradients and device interrogation revealed no arrhythmias. Six months later, he presented with acute left MCA strokes as well as new murmur, leukocytosis, and splenic infarcts on CT. TTE demonstrated a prosthetic aortic valve mean gradient of 43mmHg. TEE confirmed leaflet thrombosis with severe prosthetic aortic stenosis and mobile thrombus (Figure 1). Multiple sets of blood cultures were negative. Decision-making He was first treated with therapeutic anticoagulation but switched to broad spectrum antibiotics with increasing evidence for infection. He underwent Ross procedure with intra-operative evidence of multiple aortic root abscesses (Figure 1). PCR sequencing of the vegetation revealed staphylococcus species related to S. Haemolyticus. His course may be best explained by embolic stroke caused by progressive TAVR thrombosis in the setting of COVID-associated coagulopathy and subsequent superinfection leading to endocarditis and septic emboli. Conclusion Late TAVR thrombosis and endocarditis are rare complications. TAVR patients presenting with stroke merit prompt evaluation with dedicated echocardiographic imaging. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

ESC Asia 2022 with APSC and AFC

The proceedings contain 138 papers. The topics discussed include: cardiovascular profile and electrocardiographic findings of hospitalized adult patients during the surge of delta and omicron variants of COVID-19 in a COVID-19 tertiary referral center;abnormal left atrial strain is associated with eventual diagnosis of atrial fibrillation in patients with embolic stroke of undetermined source;sex differences in the evaluation and outcomes of multi-ethnic Asian patients undergoing stress echocardiography;intraventricular pressure gradient: a novel color M-mode echocardiographic-derived imaging modality to assess and predict the alterations following acute myocardial infarction;nationwide trends of gatekeeper to invasive coronary angiography in suspected coronary artery disease;change in minimum indexed left atrial volume predicts incident heart failure: the multi-ethnic study of atherosclerosis;and the diagnostic utility of cardiac imaging (echocardiogram and cardiac MRI) in COVID 19 patients and cardiac complications: retrospective cohort study in Saudi Arabia.

Unusual Stroke: Left Ventricular Non-Compaction Causing an Embolic Cerebrovascular Accident

Background Left Ventricular Non-Compaction Cardiomyopathy (LVNC) is a rare genetic, developmental disorder when the left apical chamber of the heart contains bundles or pieces of muscle that extend into the chamber called trabeculations. These trabeculations are a sponge-like network of muscle fibers that typically become compacted to transform heart muscle to become smooth and solid during a normal development process. Those who have LVNC most commonly are asymptomatic. Those who are symptomatic present with syncope, palpitations, dizziness, dyspnea, fatigue and/or unexplained weight gain or swelling. LVNC has also been suggested as a rare cause of embolic stroke, in our patient's case, "due to sluggish blood flow in deep intertrabecular recesses." Case We present a 29 year old African American female, G2P0011, with a history of cleft palate repair, and recent pregnancy complicated by COVID-19 who reported to ED after having a fall the day before, leg weakness and numbness, unable to walk, headache and a left facial droop on day of admission. No family history of SCD or other cardiac disease was noted. On assessment, was found to have NIHSS of 7 with rate lateral gaze palsy, left facial palsy, and decreased strength and sensation of LUE and LLE. TPA was not given due to being outside the therapeutic window. CT head and MRI brain were consistent with acute right MCA stroke. Secondary stroke workup with TTE revealed reduced LVEF 15-20%, loosely arranged myocardium with suspected LVNC and RV apical thrombus. Cardiac MRI showed increased trabeculations consistent with LVNC. Decision-making Currently, there are no ACC/AHA guidelines on anticoagulation in the setting of LVNC. Cardiology and Neurology had an extensive multidisciplinary discussion on the need for anticoagulation specifically with Warfarin. The patient was educated extensively on the need for medical adherence with anticoagulation and guideline directed medical therapy. Conclusion The patient was started on guideline directed medical therapy for cardiomyopathy and was started on Warfarin after bridging from Lovenox. She continued with physical therapy and was noted to have improvement in residual deficits at her outpatient follow up.Copyright © 2023 American College of Cardiology Foundation

Acute Myocarditis: Secondary to Viral Infection or Pheochromocytoma?

Background In a young healthy patient, acute cardiogenic shock with a dilated, thickened left ventricle is strongly suggestive of acute myocarditis. Case SM is a 33 year-old healthy man who presented with decompensated heart failure with severe hypervolemia. Notably, he was exposed to Hand-Foot-Mouth disease (HFMD) two weeks prior. B-type natriuretic peptide was elevated at 3,417 pg/mL (normal range < 50 pg/mL), and troponin was elevated. Echocardiogram revealed dilated, severe systolic dysfunction with thickened left ventricular walls. He progressed to cardiogenic shock and multi-organ failure. Right heart catheterization revealed significantly reduced cardiac output and index of 2.36 and 1.2, respectively. His course was complicated by left ventricular thrombus and subacute embolic stroke, acute renal failure and liver failure. He was treated with afterload reduction, inotropes, and diuresis. His shock resolved, and he improved with medical therapy for cardiomyopathy. Decision-making The clinical course is consistent with acute myocarditis leading to cardiogenic shock with multi-organ failure. A broad differential was considered, including viral etiologies, autoimmune diseases, vasculitis, and toxin-mediated myocarditis. Viral labs including COVID-19 and influenza, as well as HIV, and hepatitis B and C viruses were negative. Coxsackie B2 antibody was positive at 1:80, which is consistent with past or current infection. Rheumatology evaluation was unrevealing, and vasculitis was deemed unlikely given normal inflammatory markers. Urine drug screen was unrevealing. However, adrenergic myocarditis remained on the differential given an adrenal nodule noted on imaging. Plasma free metanephrines were significantly elevated, consistent with pheochromocytoma. Conclusion This is a case of acute myocarditis with two likely etiologies. The patient's presentation correlates temporally with exposure to HFMD, suggesting viral myocarditis. However, he had gross hypervolemia and diuresed 50 pounds, which suggests a more indolent course. We propose that he had adrenergic myocarditis and undetected cardiomyopathy which was exacerbated by a second insult, the Coxsackie virus.Copyright © 2023 American College of Cardiology Foundation

Left Ventricular Apical Thrombus after Covid-19 Infection Associated with Pediatric Stroke

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

Left Ventricular Non-Compaction: An Uncommon Cause of Cardoembolic Stroke

Introduction: Left ventricular non-compaction (LVNC) is a rare, usually congenital or hereditary cardiomyopathy. The formation of deep trabecular recesses increases the likelihood of a thrombus entering the systemic vasculature which may cause cardioembolic stroke. Clinical manifestations of LVNC range from asymptomatic to severe heart failure, thromboembolic events, and sudden death. In adults, individuals with LVNC have a 21 - 38% chance of developing a cardioembolic stroke. Case Presentation: We present a case of a 29-year-old African American female, six weeks postpartum with a history of cleft palate, right sixth nerve palsy, and recent Covid-19 infection who developed stroke-like symptoms of left side numbness and weakness, left side facial droop and slurred speech upon awakening. On initial examination, the patient displayed 4/5 strength and decreased sensation to pinprick in left upper and lower extremities as well as left lower facial palsy and dysarthria. CT head without contrast revealed a large infarct in the right middle cerebral artery (MCA) territory. A brain MRI confirmed the right MCA infarct but did not reveal acute infarct in other vascular territory. CTA head/neck reported right MCA proximal M2 segment occlusion. During admission, stroke work-up included a normal EKG. A transthoracic echocardiography (TTE) with bubble study was obtained which reported no patent foramen ovale but with severely reduced systolic function with a LVEF estimated 15-20%;questionable right ventricle apical thrombus was also suspected. Cardiology was consulted for acute systolic heart failure with plans to initiate goal directed medical therapy. A cardiac MRI was recommended which revealed left ventricle increased trabeculations meeting MRI criteria for LVNC, but no cardiac thrombus was detected. Patient was started on warfarin with enoxaparin bridging for secondary stroke prevention. Discussion(s): Given our case's young age of onset of stroke and the history of postpartum and recent COVID-19 infection, cardioembolic stroke due to other more common etiologies such as hypercoagulable disorders, postpartum cardiomyopathy or COVID-19 associated cardiomyopathy were initially suspected based on the initial TTE findings. Subsequent cardiac MRI revealed LVNC as an unusual cause of her cardioembolic stroke. This case illustrates the importance of thoroughly investigating the potential managementchanging causes of stroke, including congenital structural cardiac abnormalities, in patients with young age of onset.

A catastrophic case of ischemic stroke and acute myocarditis in a young patient following mRNA COVID-19 vaccination: Coincidence or consequence?

A healthy 32-years-old man was admitted in emergency department after cardiac arrest at home. He had complaints of fatigue and general malaise after Pfizer-BioNTech Coronavirus disease-2019 (COVID-19) first dose vaccine 48 hours earlier. Upon hospital admission, patient scored 3 points in Glasgow Coma Scale. Electrocardiogram showed atrial fibrillation with rapid ventricular response and a point-of-care ultrasound demonstrated severe left ventricular dysfunction with global hypokinesia. Blood tests were remarkable for elevation of high-sensitivity cardiac troponin-T and inflammatory parameters, normal platelet and fibrinogen levels and slightly increased D-dimer. A computed tomography (CT) with angiography of the cerebral arteries revealed acute ischemic posterior circulation stroke with total occlusion of the basilar artery and partial occlusion of the left vertebral artery. Life-saving systemic thrombolysis was performed but there was no clinical benefit. Pulmonary embolism was excluded. Transesophageal echocardiography showed severe left ventricular dysfunction (LVEF 30%), global hypokinesia and an apical thrombus with no other significant abnormalities. De novo multiple ischemic injuries were shown in 24h control brain CT. Once autoimmunity, thrombophilia study, PCR and serologic tests for viral infections including SARS-CoV-2 were negative, cardioembolic stroke following post-vaccinal myocarditis was suspected. Brain stem death was verified 72h later and a post-mortem endomyocardial biopsy was performed, although no signal of myocarditis was found. COVID-19 mRNA vaccination is associated with increased risk of myocarditis. We report the first known case of cardioembolic stroke and probable myocarditis after BNT162b2 first dose. This highlights that, although rare and with a predominantly favorable course, vaccine-related myocarditis can have life-threatening complications. (Figure Presented).

A Service Evaluation of Venous Thromboembolism Prophylaxis Dosing during the first COVID-19 wave in the Intensive Care Unit, Queen Alexandra Hospital Portsmouth

Introduction: In December 2019 the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Its predominant features are respiratory symptoms;however, in severe disease, coagulopathy is commonplace. Published reports from the early pandemic and emerging evidence described an increased incidence of venous thromboembolism (VTE) in these patients. Objectives: Evaluation of changes in VTE prophylaxis in patients with COVID-19 and its impact on VTE rates. Method: We performed a service evaluation of all patients admitted to ICU at Queen Alexandra Hospital (QAH) Portsmouth with confirmed COVID-19. Patients admitted from 10/03/2020 to 12/05/2020 were included. Interrogation of the computerised clinical and radiology systems were used. Patients were investigated for VTE based on clinical suspicion and observed until discharge from ICU, death, or transfer. Wealso evaluated adverse bleeding risks. Standard thromboprophylaxis for QAH is Enoxaparin, as per tables 1 and 2. Covid enhanced prophylaxis is defined in table 3. Results: 69 patients were admitted to ICU at QAH between 10/03/2020 to 12/05/2020 with confirmed COVID-19. Of these patients 37 were investigated for VTE. 17 patients had a thromboembolic event. 15 patients had a PE, of which 2 also had embolic strokes. 2 patients had a DVT. 45 patients received standard thromboprophylaxis, 18 received COVID prophylaxis, 4 received treatment dose, and 1 patient received no thromboprophylaxis. Data was unavailable for 1 patient. Adverse events were only found in 1 patient receiving treatment dose and the patient not on thromboprophylaxis. After interim analysis, on the 11th April 2021, the ICU venous thromboprophylaxis policy was changed to enhanced prophylaxis for patients being treated for COVID-19. Conclusions: This evaluation was able to identify early the increased risk of VTE in COVID patients, and the utility of ddimers to help consider VTE. The interim analysis demonstrated 50% of patients investigated had confirmed VTE. Following this analysis, along with emerging evidence and recommendations by national bodies, the VTE prophylaxis guideline was changed on the 11 April 2020 to enhanced dosing. The overall rate of confirmed VTE in our cohort was 27%. However, of those who underwent CT imaging, positive findings were found in 46%. 85% of patients admitted after 10/4/2020 were investigated for VTE, which reflects increased recognition of the issue and team confidence in transferring COVID patients. Owing to the low initial imaging rate, the evaluation is likely to have underestimated thrombosis rates. Comparing VTE rates between those who received standard and enhanced VTE prophylaxis showed no significant effect (p-value 0.425), indicating that VTE prophylaxis is unlikely to confer substantial benefit, and the low adverse event rates in both groups signal no significant harm from enhanced prophylaxis. In conclusion, this study demonstrates VTE is a significant concern in patients being treated for COVID-19 in an ICU setting. Non-peer reviewed data from large trials, suggest that anticoagulation may be of benefit in hospitalised but not intensive care patients. We continue to be guided by current evidence and still implement enhanced thromboprophylaxis in our guideline despite the equipoise demonstrated.

ACUTE STROKE MANAGEMENT DURING COVID-19 PANDEMIC

INTRODUCTION: In the coronavirus disease 2019 (COVID-19) pandemic, there may be a decrease in the number of acute stroke intervention and acute treatment, and delays in treatment periods. In this study, it was aimed to compare the clinical features of patients presenting with acute stroke during the COVID-19 pandemic and in the pre-pandemic period. METHODS: Patients hospitalized with the diagnosis of cerebrovascular disease (CVD) between January 01, 2019 and May 31, 2021 were included in the study. Demographic characteristics and stroke risk factors of the patients were recorded. Stroke type and ischemic disease subtypes were determined, and patients' admission National Institutes of Health Stroke Scale (NIHSS) score, symptom-door time, door-consultation time, door-to-door Needle time and door-groin puncture time, intravenous tissue type plasminogen activator (IV tPA) and endovascular thrombectomy (EVT) applications were recorded. Discharge modified Rankin Scale (mRS) and NIHSS scores and mortality rates were evaluated. Patients hospitalized in two separate periods of 14 months each were compared by dividing them into pre-pandemic and pandemic periods. RESULTS: Before COVID-19, 316 patients (female 45.25%, age: 66.75±13.68 years) and during the pandemic period 341 (female 41.94%, age: 68.34±13.55 years) patients were included in the study. During the pandemic period, an increase in the number of hemorrhagic CVD and transient ischemic attacks, a decrease in the number of ischemic stroke and cerebral venous thrombosis (CVT) hospitalizations, a decrease in cardioembolic strokes and an increase in lacuner ischemic CVD subtypes were observed (p<0.01). The number of large vessel atherosclerosis, IV tPA and EVT were found to be similar before and after the pandemic. In the pandemic period, although it did not reach statistical significance compared to the pre-pandemic period, prolongation was recorded in the symptom-door, door-consultation, door-needle and door-groin puncture times (p>0.05). The COVID-19 test was positive after hospitalization in 5 (1.8%) patients with ischemic stroke hospitalized during the pandemic period. During the pandemic period, admission NIHSS, discharge NIHSS and mRS scores and mortality rates were found to be significantly higher between hemorrhagic and ischemic stroke patients (p<0.01). DISCUSSION AND CONCLUSION: The COVID-19 pandemic adversely affects the management of acute stroke. The duration of acute stroke treatment is delayed due to pre-hospital and in-hospital reasons. With the heavy burden of stroke during the pandemic period, poor clinical outcome and high mortality are observed.

Natural history of coagulopathy in patients with cancer infected with COVID19: A real-world data (RWD) analysis

Background and Objective: Studies of hospitalized patients (pts) with COVID19 indicate that arterial or venous thrombotic complications occur in up to half of pts. Risk of these severe complications in pts with cancer is unknown. We estimated the incidence of arterial thrombosis (AT) and venous thromboembolism (VT) using RWD from pts with active or history of cancer with COVID19. Methods: Adult pts with cancer receiving treatment in community health systems, with COVID19 identified via ICD code or lab confirmation in 2020, were reviewed for incident AT and VT in a 90 day window following COVID19 diagnosis (index). AT was acute myocardial infarction (MI) or acute ischemic or embolic stroke (S). VT was acute deep venous thrombosis (DVT) or acute pulmonary embolism (PE). Medication use (anticoagulant, antiplatelet, statin) and comorbidities were assessed 6 months and 1 year prior to index, respectively. Results: Median age of 7,591 pts with cancer and COVID19 was 67 years and median follow up was 90 days. 32% of pts were hospitalized within 14 days, 2% received ventilator support, 6% had cardiovascular disease (CVD) and 1% had prior VT. Absolute risk of VT was significantly higher than AT (3% vs. 2%, chi square p= < 0.001), with 161 pts experiencing AT [81 (1%) MI;80 (1%) S] and 240 pts experiencing VT [99 (1%) DVT;158 (2%) PE]. This trend held across most subgroups (Table 1). The incidence rate per person-year was 0.094 for AT (0.047 MI, 0.046 S) and 0.141 for VT (0.058 DVT, 0.092 PE). CoxPH models did not show age, sex, comorbidities or medication use as significantly associated with higher probability of AT or VT. Conclusions: RWD showed pts with cancer and COVID19 were at higher risk for VT than AT. Pts who received ventilator support, or had prior VT or prior CVD had highest risk for these events. Severity of these outcomes emphasizes the need for risk reducing interventions. (Table Presented).

CARDIAC PAPILLARY FIBROELASTOMA: A RARE CAUSE OF EMBOLIC STROKE

Background and aims: Cardiac primary tumours are extremely rare. The most frequently detected are myxoma and fibroelastoma. Papillary fibroelastoma (PF) is mainly found in aortic and mitral valves. It can be diagnosed based on transthoracic echocardiography, but transesophageal echocardiography increases sensitivity among smaller tumours. PF is generally detected as an incidental finding, although it can be presented as cardiac symptomatology or embolization, being the ischemic stroke the most common presentation. We describe two ischemic stroke cases due to PF. Methods: Case 1: a 38-year-old male presented an ischemic stroke in the left posterior cerebral artery territory. Transthoracic echocardiography showed a hyperechogenic mass in the mitral valve (image 1). The examination did not show other findings. Case 2: a 66-year old male suffered an ischemic stroke in the right cerebral posterior artery territory. Usual examination did not show any pathological results. Transesophageal echocardiography showed a subvalvular mitral hyperechogenic mobile mass (11x5.5 mm) (image 2). Results: Case 1: surgical intervention extracted a 12x14 mm tumour. Histopathologic examination confirmed a PF. Case 2: surgery was postponed due to CoVid-19 pandemic. Treated with DOAC until surgery was performed. No new events. Histopathology exam confirmed the diagnosis. Neither of the patients had complications during the follow-up. No medical treatment was needed for secondary prevention. Conclusion: PF should be considered among etiological diagnoses of embolic strokes, bearing in mind secondary prevention could vary, since surgery could be a reasonable option. Transesophageal echocardiography may be a suitable option when other causes are excluded. (Figure Presented).

Presentation of Cardioembolic Stroke in Covid-19

Corona virus of 2019 was first reported on December 2019, since then so many different manifestations, complications and prognosis have been reported and being studied. Spectrum of Cardiovascular complications is seen in a case of COVID-19, from a mild myocardial injury to a full-blown myocarditis. Severe disease is usually associated with a rise in cardiac biomarkers like B-type natriuretic peptides and cardiac troponin. Most common cardiac cause of mortality in COVID-19 patients is myocarditis resulting in circulatory collapse and death. This article presents a case of COVID-19 complicated with Cardioembolic stroke related myocarditis in a 60 years old male.