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Objective: Since the last decade, the notion of minimally invasive cardiac surgery (MICS) has gained worldwide rapid popularity. Bangladesh is not far from mastering this technique due to the increasing interest of both patients and surgeons. Meanwhile, during this COVID-19 era could it help patients, remains the main question. In this context, we have operated on a total of 523 patients from October 2020 to November 2021 including, 89 patients who were MICS and among them, 17 were coronary artery bypass grafting. Method(s): We have included all patients who underwent minimally invasive coronary artery surgery in our hospital from October 2020 to November 2021 irrespective of single (MIDCAB) / multi-vessel disease (MICAS) or combined valve replacement with coronary revascularization. Data were collected from the hospital database, telephone conversations, and direct clinic visits. All data were analyzed statistically and expressed in the form of tables. Result(s): In the last 14 months of pandemics we have operated on a total of 89 MICS patients, among them 10 were Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), 6 were double or triple vessels coronary artery surgery (MICAS), 1 patient underwent upper-mini aortic valve replacement along with coronary revascularization. One of our patients needed re-exploration for chest wall bleeding on the same day. Mean ICU and hospital stay in our series were less than conventional revascularization. There was no in-hospital or 30 days' mortality in our series. Conclusion(s): Cardiac surgery these days is headed toward less invasive approaches with the aid of technology, advanced instruments, and pioneer's lead. But from our in-hospital results we conclude that by avoiding median sternotomy, these minimal invasive revascularization techniques can provide hope to the patients by alleviating symptoms with restored vascularity, reduced morbidity, preventing sudden cardiac death. Health costs reduction with shorter hospital and ICU stay are the added benefits.
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Background: Iatrogenic coronary artery dissection during diagnostic or therapeutic catheterization is a rare and mortal complication that may result in a newly developed myocardial infarction. In this study, we aimed to share the results of CABG treatment of patients with iatrogenic coronary artery dissection after coronary angiography (CAG) in our clinic. Method(s): All patients who underwent CAG or percutaneous coronary intervention (PCI) in our hospital between January 2014 and December 2021 were analyzed retrospectively and patients who underwent CABG after iatrogenic coronary artery dissection were included in the study. The dissection classification was achived according to the National Heart, Lung and Blood Institute (NHLBI) classification. Result(s): During the eight years, CAG was applied to 20,398 patients and PCI to 9583 patients. Needed to treat CABG in iatrogenic coronary artery dissection developed in 17 of the patients (0.06%). LMCA was dissected in 6 (35.3%) patients and LAD in 6 (35.3%), CX in 2 (11.8%) and RCA dissection in 3 (17.6%). 3 patients (17.6%) had an intubation time longer than 48 hours. One of them has recently had a COVID infection. Another was suffering from pulmonary edema. The other patient died on the 4th postoperative day due to low cardiac output. The length of stay in the intensive care unit was 2 (min: 1 - max: 13) days. The hospital stay was 6 (min: 4 - max: 20) days. Conclusion(s): The development of a critical clinical condition prior to surgery is strongly associated with a higher probability of early and late postoperative death. For this reason, it is clear that the treatments applied at every stage of the pre-, per-, and postoperative period are the most important determinants of the results.Copyright © 2023, CKS.
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Objective: Coronavirus disease-2019 (COVID-19), caused by a novel coronavirus, has become a worldwide pandemic. In order to control the global spread of this contagious disease, elective surgeries including cardiac and vascular procedures were postponed. In this article we present our experience during the initial phase of the pandemic in view of safety protocols. Material(s) and Method(s): The study included all elective, urgent, and emergent procedures that were performed from March 11, 2020 to June 30, 2021 at the department of cardiovascular surgery. Patients' demographics, preoperative COVID-19 (reverse transcription-polymerase chain reaction) test results, surgical procedures, complications and outcomes were prospectively collected. We also developed our own protocol to proceed with our surgical activity without delay. Result(s): A total of 86 cardiac and vascular procedures were performed during the study period. The median age was 64 years (range 23-79), 59 (69%) were males. There were 42 (48%) elective procedures, and 13 (15%) patients had emergency procedures. 57 (66%) patients underwent coronary artery bypass graft surgery. 10 (12%) patients underwent valvular procedures. Peripheral vascular surgeries were performed in 18 (21%) patients. The median length of stay in the hospital was 9 days (range 1-60). A positive COVID-19 test was identified in 4 patients, two of them were detected in the immediate postoperative period and died. In-hospital mortality was 9%. Conclusion(s): Cardiovascular procedures could be performed safely with a relatively low risk during the outbreak, particularly for elective patients with proper management and strict infection control and isolation protocols.Copyright © 2022 by Turkiye Klinikleri.
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Clinical Information Patient Initials or Identifier Number: SHS Relevant Clinical History and Physical Exam: Mr. SHS was admitted in August 2022 for acute decompensated heart failure secondary to NSTEMI, complicated with ventricular tachycardia (VT). CPR was performed for6 minutes on the day of admission and was subsequently transferred to the Cardiac Care Unit. His hospital stay was complicated with Covid-19 infection(category 2b) which he recovered well from. During admission, he developed recurrent episodes of angina. Physical examination was otherwise unremarkable. His ejection fraction was 45%. Relevant Catheterization Findings: Cardiac catheterization was performed, which revealed significant calcification of left and right coronary arteries. There was a left main stem bifurcation lesion (Medina 0,1,1) with subtotal occlusion over ostial the LAD, receiving collaterals from RCA and 90% stenosis over ostial LCx. RCA was dominant, heavily calcified with no significant stenosis. He was counselled for CABG (Syntex score26) but refused. As he was symptomatic, he was planned for PCI to the left coronary system. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: The left main was engaged with a 7F EBU 3.5guiding catheter via transradial approach. Sion Blue wired into LAD and LCx. IVUS catheter couldn't cross the LAD and LCx lesions, hence we decided for up front rotational atherectomy. Sion blue was exchanged to Rotawire with the assistance of Finecross microcatheter. A 1.5mm burr was used at 180000 rpm. After the first run of rotablation, patient developed chest pain and severe hypotension (BP ranging 50/30). 4 inotropes/vasopressors were commenced. The shock was refractory hence an intraarterial balloon pump was inserted. Symptoms and blood pressure improved. Another 2 runs of atherectomy done (patient developed hypotension after each run). IVUS examination then showed calcification of proximal to mid LAD with an IVUS Calcium score of 3. LAD was further predilated with Scoreflex balloon 3.0/20mm at 8-22ATM. LCx was predilated with Scoreflex balloon 2.0/15mm at 12-14ATM. DCB Sequent Please NEO2.0/30mm was deployed at 7ATM at ostial to proximal LCx. Proximal to mid LAD was stented with Promus ELITE 2.5/32mm at 11ATM, which was then post dilated with stent balloon at 11ATM. Ostial LM to proximal LAD (overlap) was stented with Promus ELITE 4.0/28mm at 11ATM. LMS POT was then done with NC Balloon 4.0/15mm at 24ATM. LCx was rewired and kissing balloon technique with NC balloon 4.0/15mm at 14ATM (LAD) and NC balloon 2.0/10mm at 12ATM (LCx) was done, followed by a final POT with NC balloon 4.0/15mm at 14ATM. Final IVUS showed good MSA. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This patient developed hemodynamic instability with each rotational atherectomy run, hence we decided not to perform rotablation to the circumflex artery. His hemodynamic condition improved with the use of intra aortic balloon pump. IABP use can reduce procedural event rate and potentially reduce long term mortality in appropriately selected patients who are at high risk of adverse events. He was followed up a month following the procedure and remained asymptomatic. For complex, calcified coronary lesions involving the left main stem, coronary artery bypass graft surgery is an alternative option.Copyright © 2023
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Background During the coronavirus disease 2019 (COVID-19) pandemic first wave, elective coronary artery bypass graft (CABG) surgeries were postponed. However, urgent surgeries were upheld for high-risk patients. The outcomes and characteristics of patients infected by SARS-CoV-2 in the perioperative period of CABG are unknown. Methods All patients who underwent CABG in a large reference medical center in Brazil between April 2020 and May 2021 were analyzed. COVID-19 infection was confirmed by positive nasal swab PCR testing. We compared mortality, length of hospital stay and need for dialysis as outcomes among patients with and without clinical COVID-19 infection. Results Among the 303 patients who underwent urgent CABG, 30 (9.9%) were infected by SARS-CoV-2. COVID diagnosis was made within 10 days after surgery in 17 patients (56%) while only one patient (3.3%) had a pre-CABG positive test with surgery performed 16 days later. Infected and non-infected patients had similar hypertension, diabetes, dyslipidemia and previous myocardial infarction rates, as well as preoperative left ventricular ejection fraction. There were more smokers among the non-infected group (p < 0.001), and a greater rate of urgent and emergency procedures among COVID positive patients (83.3%) compared to the non-COVID group (62.3%) (p=0.026). No differences were observed with respect to type and number of grafts used. However, we found statistically significant differences in all measured outcomes. Mortality was meaningfully higher in patients infected by SARS-CoV-2 (53.3% vs 8.1%;p <0.001), as well as the need for dialysis (36.7% vs 4.4%;p 0.001). COVID-19 infection was also associated with a longer hospital stay, with a mean time of 40.5 days in the COVID group, compared to 18.2 days in non-COVID group (p=0.026). Conclusion This study showed that COVID-19 infection during hospitalization in which emergency and urgent CABG surgery had to be performed was associated with worse outcome: 6.5 greater mortality and also greater morbidity (need for dialysis and length of hospital stay) were documented in the infected compared to the non-infected group.Copyright © 2023 American College of Cardiology Foundation
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Background We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the sixteen years after Hurricane Katrina. Methods This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years prior to Hurricane Katrina and sixteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Results In the sixteen-year post-Katrina period, there were 3696 admissions for AMI out of a total census of 128,276 (2.9%) compared to 150 admissions out of a census of 21,079 (0.7%) in the pre-Katrina group (p<0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (43.8% vs. 30.7%, p<0.0001), diabetes mellitus (40.7% vs. 28.7%, p<0.002), hypertension (80.1% vs. 74.0%, p<0.05), hyperlipidemia (54.2% vs. 44.7%, p<0.0001), smoking (54.2% vs. 39.3%, p<0.0002), drug abuse (18.7% vs. 6.7%, p<0.0002), and psychiatric disease (15.3% vs. 6.7%, p<0.0004). The post-Katrina group was more often prescribed aspirin (49.6% vs. 31.3%, p<0.0001), beta-blocker (46.9% vs. 34.0%, p<0.004), ACE inhibitor or ARB (51.9% vs. 36.0%, p<0.0004), and statin (52.6% vs. 28.0%, p<0.0001) but with higher medication non-adherence (15.8% vs. 7.3%, p<0.0001). The post-Katrina patients were also more likely to be unemployed (75.6% vs 22.7%, p<0.0001) and non-married (56.3% vs. 52.7%, p<0.0001). Rates of STEMI were lower in the post-Katrina group (29.1% vs 42.0%, p<0.002). There was no significant difference in terms of sex, being uninsured, or prior coronary artery bypass grafting. Four patients were COVID positive in the post-Katrina cohort. Conclusion There was a 4-fold increase in the incidence of AMI sixteen years after Hurricane Katrina. Psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post-Katrina group. These findings add to the growth of literature demonstrating the adverse cardiovascular outcomes that occur after a natural disaster. Further research is needed to explain the underlying mechanisms to help diminish future cardiac morbidity.Copyright © 2023 American College of Cardiology Foundation
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The COVID-19 pandemic has brought global health services to a standstill. National healthcare systems and medical staffing in many countries have reached crisis levels due to the phenomenal outbreak. Healthcare resources have been strained to meet the unprecedented numbers of patient admissions with a significant amount of funding and manpower being channelled towards tackling this global pandemic. Despite the rollout of vaccinations, the development of new viral strains has now presented a new challenge. With the inevitable conversion of tertiary public hospitals to specialized COVID-19 centres with 'Full Covid Status' and the mobilization of its doctors from all specialities to care for these patients, the non-COVID-19 patients are becoming more neglected. The lack of elective surgeries performed and non-emergent admissions due to the unavailability of beds and personnel to care for this group of patients are concerning. As most of the focus and resources are now aimed at COVID-19 patients, the need to forge collaborations and cooperation between hospitals, agencies and healthcare systems are pertinent to ensure the provision of quality treatment for those suffering from non-COVID-19 diseases. To highlight this effort in Malaysia, we would like to present 2 case studies of non-COVID-19 patients undergoing elective surgeries through intergovernmental ministerial collaborations and a public-private partnership.Copyright © The Author(s) 2022.
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Aim: Coronavirus disease 2019 (COVID-19) has caused thrombotic disease. In this study, we aimed to determine the demographic and clinical characteristics of acute coronary syndrome (ACS) patients infected with COVID-19 and to investigate whether they differ from patients with ACS without COVID-19 in terms of these characteristics. Material(s) and Method(s): The study was designed as a single-center retrospective study. Thirty-three COVID-19 infected ACS patients (Group 1) and 100 ACS patients without COVID-19 infection (Group 2) were included in the study. Result(s): The groups were compared in terms of coronary angiographic data. Twenty-eight (84.8%) patients in Group 1 and 74 (74%) patients in Group 2 were presented as non-ST elevation myocardial infarctus. Patients were compared in terms of baseline Thrombolysis in Myocardial Infarctus (TIMI) flow, thrombus stage, myocardial blush (end), using of thrombus aspiration catheter, stent thrombosis, and TIMI flow after percutaneous coronary intervention, and it was observed that there was no statistical difference between the groups (p> 0.05). Discussion(s): COVID-19 infection can cause plaque rupture, myocardial damage, coronary spasm and cytokine storm by triggering the coagulation and inflammation process. The fact is that we did not encounter an increased thrombus load in this study.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Pseudoaneurysm of the thoracic aorta is a rare condition associated with high mortality. We present a case of a patient who developed a huge pseudoaneurysm 10 years after the Bentall procedure and one aortocoronary bypass while simultaneously being COVID-19 positive. After treating pneumonia, the surgery was successfully performed with suturing two defects in the aortic conduit. It is a unique case report where the patient survived two life-threatening conditions.Copyright © 2023, CKS.
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Upon initial discovery in late 2019, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, has managed to spread across the planet. A plethora of symptoms affecting multiple organ systems have been described, with the most common being nonspecific upper respiratory symptoms: cough, dyspnea, and wheezing. However, the cardiovascular system is also at risk following COVID-19 infection. Numerous cardiovascular complications have been reported by physicians globally, in particular cardiac tamponade Physicians must hold a high index of suspicion in identifying and treating patients with cardiac tamponade who may have contracted the novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2 and cardiac tamponade, highlighting their clinical course progression and the implications it may have for the severity of both illnesses. The paper will also review published case reports of cardiac tamponade, clinical presentation, and treatment of this complication, as well as the disease as a whole. © 2022 Elsevier Inc.
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Purpose of Study:We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans in the sixteen years after Hurricane Katrina. Methods Used: This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years prior to Hurricane Katrina and sixteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Summary of Results: In the sixteen-year post-Katrina period, there were 3696 admissions for AMI out of a total census of 128 276 (2.9%) compared to 150 admissions out of a census of 21 079 (0.7%) in the pre-Katrina group (p < 0.0001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (43.8% vs. 30.7%, p < 0.0001), diabetes mellitus (40.7% vs. 28.7%, p < 0.002), hypertension (80.1% vs. 74.0%, p < 0.05), hyperlipidemia (54.2% vs. 44.7%, p < 0.0001), smoking (54.2% vs. 39.3%, p < 0.0002), drug abuse (18.7% vs. 6.7%, p < 0.0002), and psychiatric disease (15.3% vs. 6.7%, p < 0.0004). The post-Katrina group was more often prescribed aspirin (49.6% vs. 31.3%, p < 0.0001), betablocker (46.9% vs. 34.0%, p < 0.004), ACE inhibitor or ARB (51.9% vs. 36.0%, p < 0.0004), and statin (52.6% vs. 28.0%, p < 0.0001) but with higher medication nonadherence (15.8% vs. 7.3%, p < 0.0001). The post- Katrina patients were also more likely to be unemployed (75.6% vs 22.7%, p < 0.0001) and non-married (56.3% vs. 52.7%, p < 0.0001). Rates of STEMI were lower in the post-Katrina group (29.1% vs 42.0%, p < 0.002). There was no significant difference in terms of sex, being uninsured, or prior coronary artery bypass grafting. Four patients were COVID positive in the post-Katrina cohort. Conclusion(s): There was a fourfold increase in the incidence of AMI sixteen years after Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post- Katrina group. These findings will continue to add to the growing body of literature demonstrating the adverse cardiovascular outcomes that occur after a natural disaster. Despite this, further research is required to explain the underlying mechanisms to help mitigate future cardiac morbidity. This study will help enable cardiovascular clinicians to further understand the needs and dynamic changes that can occur following natural disasters. Copyright © 2023 Southern Society for Clinical Investigation.
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Background: Cardiac calcification is a broad entity encompassing calcific deposits in the valves, coronary arteries, aortic root, myocardium, endocardium, or pericardium. It is reported in approximately 19 percent of post myocardial infarction (MI) patients. (1) Coronary artery disease is by far the commonest cause of endo-myocardial calcification, other causes include endomyocardial fibrosis, myocarditis, metastatic calcification in chronic kidney disease patients. Post - acute coronavirus (COVID) syndrome is defined as the persistence of symptoms even beyond 4 weeks of onset of acute symptoms. (2) A recent study has shown that, beyond the first 30 days after infection, individuals with COVID are at increased risk of incident cardiovascular disease including cerebrovascular disorders, dysrhythmias, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure and thromboembolic disease. (3) This study cited the risk and additional burden of ischemic heart disease outcome as an hazard ratio of 1.66 (95% confidence interval of 1.52 - 1.80) and 7.28 (95% confidence interval 5.8 - 8.88) per 1000 population respectively. (3) We present an interesting case of a forty-three-year-old man with endo-myocardial calcification with ischemic cardiomyopathy (ICMP) and severely reduced left ventricular (LV) global longitudinal strain (GLS) in post COVID syndrome. Case report: A forty - three-year-old man presented to us with gradually worsening dyspnea on exertion - New York Heart Association (NYHA) grade II at present - and pedal edema since the past 6 months. He had a history of COVID infection prior to that for which he received institutional care and was discharged uneventfully - not requiring any intensive care stay during the hospitalization. On presentation now a 12-lead electrocardiogram was done which revealed left bundle branch pattern. He underwent - an echocardiogram which showed a reduced ejection fraction of 38 % along with regional wall motion abnormality in anterior, apical and lateral wall;a computed tomogram of thorax which did not reveal any lung disease but endo - myocardial calcification. (Fig 3) He further underwent myocardial strain imaging using echocardiography, which revealed a severely reduced LV GLS. (Fig 4) Routine blood investigations including inflammatory markers and Troponin levels were within normal limit, brain natriuretic peptide (BNP) levels were found to be very high. The patient underwent coronary angiogram which revealed significant disease in distal left main coronary artery and ostio-proximal left anterior descending and left circumflex artery. After detailed heart team discussion along with patient relatives the patient was advised coronary artery bypass grafting. The patient took discharge and went to a different hospital to undergo the same. Conclusion(s): Acute Coronavirus infection has already been wreaking havoc all around the globe since the past 3 years. We have now showcased a unique and devastating consequence of the post COVID state in a relatively young man. [Formula presented] [Formula presented] Copyright © 2022
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Background: FSGS is a histologic pattern of glomerular injury with numerous causes, frequently associated with kidney disease progression and kidney failure. Although CVD events are known to be associated with end stage kidney disease (ESKD), there is a paucity of research examining this relationship in the FSGS population. We assessed the impact of baseline proteinuria and eGFR decline to ESKD on CVD event incidence and all-cause mortality. Method(s): A descriptive, retrospective analysis using Optum de-identified Market Clarity and proprietary Natural Language Processed (NLP) Data (2007-2020). Inclusion criteria: Patients (>=18yo) with >=2 FSGS ICD-10 codes (N031, N041, N051, N061, N071) and/or >=2 FSGS NLP terms within 180 days and >=30 days apart without associated negation terms, >6mo pre-index activity (exclusion: COVID-19). Post-index CVD events included myocardial infarction (MI), ischemic stroke/transient ischemic attack (TIA), unstable angina, congestive heart failure (CHF), percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). All-cause mortality included patients with a death date post-index. Result(s): Overall (n=7,974), 11.7% of patients with FSGS experienced a CVD event. Post-ESKD, and among patients with higher baseline proteinuria, CVD events and mortality were significantly elevated (p<.001;Table 1). Conclusion(s): A significant increase in CVD events and death was associated with elevated proteinuria and progression to ESKD in patients with FSGS. New therapies for FSGS that reduce proteinuria may reduce CVD events and improve overall survival. (Table Presented).
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SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: It is well established that SARS-CoV-2 infection predisposes patients to develop thromboses. Here we present an elderly Hispanic male with who was hospitalized for COVID-19 pneumonia and was on therapeutic anticoagulation, yet still developed an acute right coronary artery occlusion secondary to thrombus formation. CASE PRESENTATION: An 81 year-old Hispanic male with hypertension, coronary artery bypass graft (LIMA to LAD and SVG to OM), congestive heart failure was admitted to the hospital for SARS-CoV-2 pneumonia. Inflammatory markers were elevated with a D-Dimer level of 2.95 mg/mL. An EKG at that time showed normal sinus rhythm with a heart rate of 69 bpm and no ST-T wave abnormalities. Troponin-I level was unremarkable. He was started on remdesivir, steroids, and continuous heparin infusion. During hospital stay, the patient’s overall clinical status continued to improve. On day 9, the patient started complaining of 9/10 intensity, non-radiating substernal squeezing chest pain. He appeared diaphoretic. A STAT 12-lead EKG showed ST elevations in the inferior leads concerning for Inferior Wall MI (IWMI). The patient was immediately taken to the catheterization lab. The right coronary artery (RCA) had 99% stenosis with filling defect secondary to thrombus in its proximal, middle, and distal portion. Thrombus removal was achieved with a thrombectomy catheter and patient received two drug eluting stents (DES) in the proximal and distal RCA. The patient was continued on heparin infusion, aspirin 81mg daily, clopidogrel 75mg daily, and atorvastatin 80mg daily. He was discharged home two weeks later and had good outpatient follow up. DISCUSSION: ST-segment elevation myocardial infarction (STEMI) is commonly encountered in patients with COVID-19 infection. About 40% of COVID-19 patients with STEMI had no evidence of coronary artery disease (CAD) which excludes Type I Myocardial Infarction (MI). This suggests that a large proportion of patients had Type II MI. Our patient developed an occlusive thrombus requiring thrombectomy. It is difficult to know in this case whether the patient may have still suffered a STEMI without the hypercoagulable state from COVID-19 infection since he already had underlying CAD. Incidence rates of STEMI in patients with COVID-19 infection are variable (0.3-11%). Nonetheless, we can highlight the fact that SARS-CoV-19 remains a significant risk factor for STEMI. Acute thrombus formation causing STEMI is an uncommon occurrence. CONCLUSIONS: This case emphasizes the hypercoagulable state in the setting of SARS-CoV-2 infection and encourages clinicians to be mindful of the potential complications that can affect nearly all organ systems. It is important for clinicians to acknowledge that patients with COVID-19 infection may develop blood clots despite systemic anticoagulation. Further investigation is needed to address the management of these patients after thrombectomy. Reference #1: Kermani-Alghoraishi, M. (2021). A Review of Coronary Artery Thrombosis: A New Challenging Finding in COVID-19 Patients and ST-elevation Myocardial Infarction. Current Problems in Cardiology, 46(3), 100744. https://doi.org/10.1016/j.cpcardiol.2020.100744 Reference #2: Green, C., Nadir, A., Lester, W., & Dosanjh, D. (2021). Coronary artery thrombus resulting in ST-elevation myocardial infarction in a patient with COVID-19. BMJ Case Reports, 14(8), e243811. https://doi.org/10.1136/bcr-2021-243811 Reference #3: Genovese, L., Ruiz, D., Tehrani, B., & Sinha, S. (2021). Acute coronary thrombosis as a complication of COVID-19. BMJ Case Reports, 14(3), e238218. DISCLOSURES: No relevant relationships by Utku Ekin No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel
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Background: Limited data exist on the clinical outcomes of patients with coronavirus disease 2019 (COVID-19) presenting with ST-segment-elevation myocardial infarction (STEMI). Method(s): This multicenter study, conducted in 6 centers in Iran, aimed to compare baseline clinical and procedural data between a case group, comprising STEMI patients with COVID-19, and a control group, comprising STEMI patients before the COVID-19 pandemic, and to determine in-hospital infarct-related artery thrombus grades and major adverse cardio-cerebrovascular events (MACCEs), defined as a composite of deaths from any cause (cardiovascular and noncardiovascular), nonfatal strokes, and stent thrombosis. Result(s): No significant differences were observed between the 2 groups regarding baseline characteristics. Primary percutaneous coronary intervention (PPCI) was performed in 72.9% of the cases and 98.5% of the controls (P=0.043), and primary coronary artery bypass grafting was performed in 6.2% of the cases and 1.4% of the controls (P=0.048). Successful PPCI procedures (final TIMI flow grade III) were significantly fewer in the case group (66.5% vs 93.5%;P=0.001). The baseline thrombus grade before wire crossing was not statistically significantly different between the 2 groups. The summation of thrombus grades IV and V was 75% in the case group and 82% in the control group (P=0.432). The rate of MACCEs was 14.5% and 2.1% in the case and control groups, respectively (P=0.002). Conclusion(s): In our study, the thrombus grade had no significant differences between the case and control groups;however, the in-hospital rates of the no-reflow phenomenon, periprocedural MI, mechanical complications, and MACCEs were statistically significantly higher in the case group. Copyright © 2022 Tehran University of Medical Sciences.
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Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P<0.001). A later six months follow-up showed that two out of 12 (16.6%) COVID-19 positive OHT patients died. There was no statistically significant difference between the prevalence of COVID-19 in our patients compared to Iran’s general population (P=251.0). Non-compliance with personal protective protocols and a history of contact with COVID-19 cases were the most risk factors for COVID-19 infection in OHT patients.
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Methodology and case description: Case 1: A 55-year-old hypertensive male with complaints of chest pain presented to the cardiology department. He underwent angiography to reveal triple vessel disease and was scheduled for coronary artery bypass graft surgery. During preoperative evaluation, patient gave a history of having suffered from mild COVID-19, getting cured with conservative management under home isolation 3 months back. Examination revealed bilateral basal crepitations. Chest X-ray was indicative of fibrosis basal areas of both lungs (right > left) which was confirmed by HRCT chest. Preoperatively the patient was optimised with antifibrotic agent nintedanib and methylprednisolone. He was reviewed after 1 month and had shown significant-resolution radiologically as well as clinically (improved breath holding time, saturation and lung auscultation). Intraoperative course was uneventful and the patient was ventilated with low tidal volume. Postoperatively, the patient was extubated on day 1. Patient experienced difficulty in expectoration which was improved by N-acetyl cysteine administered intravenously and via nebulisation along with active vigorous physiotherapy. Patient was discharged on the 7th postoperative day. Case 2: A 37-yearold female, a known case of severe mitral stenosis, moderate pulmonary hypertension, moderate tricuspid regurgitation was under conservative management with diuretics and beta-blockers and was being planned for mitral valve replacement. The patient had developed COVID-19 infection 1 month back and was treated under home isolation and conservative management. However, the patient presented with an increase in exercise intolerance post COVID infection. Suspecting the possibility of fluid overload/ heart failure and pulmonary hypertension, the diuretic dose was increased post admission, but to no avail. Chest X-ray and HRCT chest were done which highlighted the possibility of allergic bronchopulmonary aspergillosis;which has been described as one of the rare findings coexisting with active COVID-19 infection. This was confirmed by the serum IgE levels and presence of eosinophilia in the complete blood picture. The patient was initiated on itraconazole and methylprednisolone which resulted in improvement in breathlessness over the next 3 weeks. The patient was subsequently posted for surgical replacement of the mitral valve. Intra-operative and post-operative course was uneventful and the patient was discharged on 5th post-operative day. Conclusion: These 2 cases who had suffered from mild COVID-19 infection presented significant challenges for safe intra- and post-operative conduct of anaesthesia. These challenges were overcome by efficient prehabilitation and optimisation of the patient and optimal post-operative critical care. Intra-operative course is often just a small segment of the overall hospital course of the patient and the role of critical care in the pre-surgical, extra-hospital care along with post-operative care needs acknowledgement and recognition.
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During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.
ABSTRACT
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.