Acute or chronic? Failing left ventricle in a 34 year old

Submission content Introduction: An unusual case of a very young patient without previously known cardiac disease presenting with severe left ventricular failure, detected by a point of care echocardiogram. Main Body: A 34 year old previously well man was brought to hospital after seeing his general practitioner with one month of progressive shortness of breath on exertion. This began around the time the patient received his second covid-19 vaccination. He was sleeping in a chair as he was unable to lie flat. Abnormal observations led the GP to call an ambulance. In the emergency department, the patient required oxygen 5L/min to maintain SpO2 >94%, but he was not in respiratory distress at rest. Blood pressure was 92/53mmHg, mean 67mmHg. Point of care testing for COVID-19 was negative. He was alert, with warm peripheries. Lactate was 1.0mmol/L and he was producing more than 0.5ml/kg/hr of urine. There was no ankle swelling. ECG showed sinus tachycardia. He underwent CT pulmonary angiography which demonstrated no pulmonary embolus, but there was bilateral pulmonary edema. Troponin was 17ng/l, BNP was 2700pg/ml. Furosemide 40mg was given intravenously by the general medical team. Critical care outreach asked for an urgent intensivist review given the highly unusual diagnosis of pulmonary edema in a man of this age. An immediate FUSIC Heart scan identified a dilated left ventricle with end diastolic diameter 7cm and severe global systolic impairment. The right ventricle was not severely impaired, with TAPSE 18mm. There was no significant pericardial effusion. Multiple B lines and trace pulmonary effusions were identified at the lung bases. The patient was urgently discussed with the regional cardiac unit in case of further deterioration, basic images were shared via a cloud system. A potential diagnosis of vaccination-associated myocarditis was considered,1 but in view of the low troponin, the presentation was felt most likely to represent decompensated chronic dilated cardiomyopathy. The patient disclosed a family history of early cardiac death in males. Aggressive diuresis was commenced. The patient was admitted to a monitored bed given the potential risk of arrhythmia or further haemodynamic deterioration. Advice was given that in the event of worsening hypotension, fluids should not be administered but the cardiac centre should be contacted immediately. Formal echocardiography confirmed the POCUS findings, with ejection fraction <35%. He was initiated on ACE inhibitors and beta adrenergic blockade. His symptoms improved and he was able to return home and to work, and is currently undergoing further investigations to establish the etiology of his condition. Conclusion(s): Early echocardiography provided early evidence of a cardiac cause for the patient's presentation and highlighted the severity of the underlying pathology. This directed early aggressive diuresis and safety-netting by virtue of discussion with a tertiary cardiac centre whilst it was established whether this was an acute or decompensated chronic pathology. Ultrasound findings: PLAX, PSAX and A4Ch views demonstrating a severely dilated (7cm end diastolic diameter) left ventricle with global severe systolic impairment.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) complicating myocarditis

Myocarditis can lead to myocardial infarction in the absence of coronary artery obstruction. We report a case of probable myocarditis, complicated by myocardial infarction with non-obstructive coronary arteries. A 19-year-old man presented with chest pain typical of myocarditis. He was a smoker but was otherwise well. Electrocardiogram revealed diffuse ST-elevation and echocardiography revealed a thin, akinetic apex. Troponin-T levels on admission were raised leading to an initial diagnosis of myocarditis being made. However, late gadolinium enhancement study on cardiac magnetic resonance imaging demonstrated transmural enhancement typical of ischaemia. Coronary angiogram was normal, leading to a likely diagnosis of myocardial infarction with non-obstructive coronary arteries. It is important to highlight that coronary assessment remains important when working up for myocarditis, as myocardial infarction with non-obstructive coronary arteries can often complicate myocarditis in cases of normal angiography. Another important lesson was on how cardiac magnetic resonance imaging provided vital evidence to support underlying ischaemia despite normal coronary angiogram, leading to a diagnosis of myocardial infarction with non-obstructive coronary arteries. Myocardial infarction with non-obstructive coronary arteries remains a broad 'umbrella' term and cardiac magnetic resonance imaging, as well as more invasive coronary imaging techniques during angiography, can further assist in its diagnosis. Our case provides a reminder that myocardial infarction with non-obstructive coronary arteries, although increasingly recognised, remains under-diagnosed and can often overlap with peri-myocarditis, highlighting the need to employ multi-modality imaging in guiding management.Copyright © The Author(s) 2021.

Endemic Covid Is Contributing to Significant Excess Cardiac Mortality

Background In the USA and other countries, cardiac deaths have been elevated above background rates since the start of the COVID pandemic. This could be directly due to COVID or indirectly due to health system dysfunction (reduced access to optimal cardiac care during pandemic years). Methods Analysis of rates of circulating respiratory viruses, vaccination and cardiac death rates compared to background/usual in multiple countries. Results Cardiac deaths in the USA and most other countries with cause-specific data available since 2020, have been elevated. Excess mortality due to cardiac causes in 2021 was higher in countries with low vaccination rates against COVID. An exception to this trend has been Australia in 2021. In 2022, Australia (like other countries) exhibited elevated rates of cardiac deaths compared to baseline. In 2021, when Australia was pursuing a COVID-zero policy of lockdowns and border closures, which also led to a near Influenza-zero status, cardiac deaths were substantially reduced compared to baseline (Figure). Conclusion The relationship between circulating respiratory virus rates and cardiac deaths is strong in both directions, indicating likely direct causation. In hindsight, this relationship also explains pre-pandemic winter spikes and summer drop-offs in cardiac deaths. Although "COVID fatigue" is common, a policy allowing high rates of circulating COVID and tolerating sub-optimal vaccination rates directly leads to excess cardiac deaths. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Low Rate of Major Adverse Cardiovascular Events in Patients Presenting to Urgent Care With Chest Pain and a Moderate HEART Risk Score Who Were Referred for an Expedited Outpatient Cardiology Evaluation

Introduction: The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The low rate of major adverse cardiovascular events (MACE) in patients with a moderate risk HEART score referred from an urgent care (UC) center for an expedited outpatient cardiology evaluation was first described by this group in 2020. This is a follow up study with a total of 446 patient over a 36 month period. Hypothesis: Patients with a moderate risk HEART score who present to the ED are usually hospitalized for further evaluation. The safety of outpatient evaluation of these patients is not well studied. We assessed the hypothesis that there is a low rate of MACE when patients with a moderate risk HEART score were referred from an UC for an expedited outpatient cardiology follow up. Method(s): A cross sectional study was performed from 2/14/2019 through 3/30/2022 in 5 UC centers of 446 patients who presented with chest pain or anginal equivalent and a HEART score of 4 to 6 in Las Vegas, Nevada. A streamlined disposition protocol was adopted by all UC providers for an expedited outpatient cardiology instead of ED referral. The population was followed for 6 weeks with a primary endpoint of MACE (death, myocardial infarction (MI), revascularization) determined by electronic medical records review and direct phone contact with patients. Outcomes were confirmed in 93% of patients. Result(s): The average age was 65 years with 52% female and 48% male. 395 patients (89%) were seen by a cardiology provider, 346 patients (88%) were seen within 3 days. 265 stress tests (67%), 42 coronary CT angiograms (11%) and 19 invasive coronary angiograms (5%) were ordered. 8 patients (2%) were found to have MACE: 2 had routine surgical revascularization, 4 had non-fatal MI followed by revascularization, 2 patients died: 1 was urgently referred for mitral valve replacement and died after surgery from renal failure and COVID, the other patient died from COVID pneumonia. There were no ischemic cardiac deaths. Conclusion(s): In conclusion, patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no ischemic cardiac deaths due to delay of care.

Real World Experience Utilizing Donor Kidneys at Risk for Acute Kidney Injury with Belatacept Based Maintenance Immunosuppression

Purpose: The demand for kidney transplant continues to rise, and limited supply has encouraged acceptance of marginal donor organs, such as those at risk for acute kidney injury (AKI). We evaluated the utilization of such organs (defined as donation after cardiac death, pediatric donors, kidneys with a cold ischemic time >24 hrs, terminal serum creatinine (SCr) >2mg/dL or rising SCr with decreasing urine output at donation) at our center who were discharged on belatacept based maintenance immunosuppression with mycophenolate and steroids (BBMS). Method(s): This retrospective, descriptive study examined kidney transplant recipients (KTR) who received AKI organs and were discharged on BBMS between 1/2019-4/2021. Primary outcome assessed graft function and rejection at 6 & 12 months (mos) post-transplant (txp). Secondary outcomes evaluated graft failure, mortality, infection, DSA & changes to BBMS. All outcomes were evaluated at 1yr if records were available. Result(s): 68 KTR w/1 yr results & 52 w/6 mo results on BBMS were included. Baseline characteristics (Table 1) show most KTR received a DCD or en bloc organ and lymphocyte depleting induction. Mean eGFR improved from 1 to 6 mo post-txp and was stable through 1yr. Episodes of biopsy proven rejection were more common during the first 6mos post-txp. There were 2 deaths during the study period, due to COVID, and no graft failures. Twelve KTR developed DSA. There were 21 KTR with CMV viremia, mostly in moderate risk group, & 12 with BK viremia. Table 4 shows changes to BBMS occurred in 32 KTR. Most KTR required multiple BBMS changes with most common dose adjustments to mycophenolate due to leukopenia or neutropenia. Conclusion(s): Utilization of AKI organs with BBMS in KTR at our center resulted in no graft failures & sustained eGFR despite more rejection episodes during the first 6mos post-txp. Although 32 KTR had changes to BBMS, only 5 KTR had rejection following a change. Incidence of CMV was common but did not impact KTR outcomes. Overall, BBMS could be a promising option in AKI organs to avoid nephrotoxicity associated with CNI based regimens. These findings suggest the need to further evaluate the impact of long-term outcomes associated with changes made to BBMS in AKI donor organs.

Organ donation rates during the COVID-19 pandemic: Comparing the approach taken during the first two waves

Introduction: In response to the COVID-19 pandemic the many UK transplant units had to close or reduce activity, with deceased donation and transplantation down 80% in March-May 2020. Donor age criteria were reduced in the first wave to protect ICU capacity, and donation after brain death (DBD) was prioritised over donation after cardiac death (DCD). From June onwards, an NHSBT recovery plan aimed to reopen programmes, with the aim to return to a position of exploring all eligible donors and reviewing their potential on a case-by-case basis,1 but the ability of such programmes was impacted by a further rise in COVID-19 cases (second wave). Objectives: We aimed to compare the performance of NHSBT referral, donation, and transplantation strategies during the first two waves of COVID-19. Wave one was defined as 11/3/20 to 10/8/20, and wave two 11/8/20 to 10/3/21. Methods: Mortality and transplant data were acquired from the Potential Donor Audit (PDA) and national transplant registries. COVID-19 healthcare utilisation data was acquired via the PHE API. Correlation between features were assessed using Pearson's product-moment correlation coefficient and means compared using Student's t-test. Results: Weekly referral rates during the first wave were strongly inversely correlated to COVID-19 critical care utilisation (r=-0.82, 95%CI -.93 to -0.60) but moderately positively correlated during the second (r=0.61, 95%CI 0.31 to 0.80). Total transplanted organs were inversely correlated throughout (r=-0.64, 95%CI -0.78 to -0.44) with no difference between waves (p=0.055), although renal transplants were less effected during the second wave (p<0.001). The mean transplant gap (difference between organs retrieved and transplanted) was significantly higher in the second wave (5.9 per week, 95%CI 3.4 to 8.5, p<0.001). The DBD/DCD ratio was significantly lower in the second wave (reduced from 3.3 to 2.0, 95%CI for reduction 0.5-2.1, p=0.001). Conclusion: Referral rates to NHSBT improved during the second wave, and the ratio of DBD to DCD fell, both reflecting positively on the change of approach taken. Although total organ transplants fell during both waves, this is strongly correlated to critical care utilisation by COVID-19 patients, suggesting an impact on the ability for transplant centres to access critical care resources post-operatively. The relative sparing of renal transplants (who rarely require critical care post-operatively) and increasing transplant gap in the second wave fits with this assessment, although concerns regarding risks of COVID-19 in transplant recipients -especially in renal patients2-during periods of high burden of disease in hospital likely also contributed to reduced transplant rates,3 and the higher transplant gap could additionally be associated with the increase in DCD donation during the second wave.4.

TCTAP A-019 Short Term and Mid Term Outcomes of Intravascular Lithotripsy (IVL) in Patients With Moderate to Severe Calcific Coronary Artery Disease (CAD)

Background: Moderate to severe coronary calcification results in suboptimal results with increased risk of procedural and future adverse events. Newer high-pressure balloons and atherectomy devices have not shown any superiority over the routine high pressure balloon dilatation. Intravascular lithotripsy (IVL) is the latest technique for treatment of moderate to severe calcific coronary artery disease. IVL converts the electrical energy into mechanical energy with cracking of calcium in both adventitia and intima. DISRUPT CAD III study has shown the short-term outcomes of Intravascular lithotripsy (IVL). However, the experience is limited with this new technique especially for mid-term and long-term outcomes. The Coronary IVL System is a proprietary balloon catheter system designed to enhance stent outcomes by enabling delivery of the calcium disrupting capability of lithotripsy prior to balloon dilatation at low pressures. The Coronary IVL System consists of an IVL Balloon Catheter with two integrated pairs of lithotripsy emitters, a Lithotripsy Generator, and Connector Cable. Methods: Our study is a single centre, observational study done at Apollo hospitals, Visakhapatnam, India, to evaluate the safety, mid-term and long-term effectiveness of Intravascular Lithotripsy (IVL). Subjects who are more than 18 years of age with moderate to severe calcification which require Percutaneous Coronary Intervention (PCI) and are willing to participate in the study are included. Baseline parameters were assessed. Procedural success was defined as no residual stenosis of <30% after stenting. Procedural and postprocedural complications were noted. Usage of adjuvant Atherectomy balloons or devices is noted. Both clinical and angiographic follow up was done. Clinical follow up parameters assessed were MACE which includes cardiac death, MI, target vessel revascularisation (TVR), Target lesion revascularisation (TVR). Any admissions for heart failure or change in functional class are also noted. On follow up, Angiographic assessment was done for In-stent restenosis (>50%) or In segment restenosis (>50%) or any fresh coronary lesions which mandates revascularisation. Results: Out of 35 subjects, only 2 were females. Mean age was 69.9 ± 2.8 years. 15 (42.8%) subjects were Diabetics and 17 (48.5%) were Hypertensives. 2 subjects underwent previous CABG surgery. 10 subjects had left ventricular dysfunction. 2 subjects had renal dysfunction. 29 (82.8%) subjects presented with Acute MI out of which 22 were presented with NSTEMI. 1 subject underwent the procedure during Primary PTCA successfully. Total number of stents implanted were4 1 with a mean stent implantation was 1.17. Rotablation system (Boston Scientific) was used in 2 subjects prior to IVL where the intimal calcium was extensive. OPN NC balloon (Translumina Therapeutics) was used in 6 subjects. Mean stent length was 35.9 ± 9.8 mm. Mean number of pulses delivered was 7.3 ± 1.4. All the subjects had good procedural outcomes with no residual stenosis. Only 1 subject had coronary dissection after IVL which could be stented successfully. 1 subject had an aneurysm in the proximal LAD which could be stented. Subjects were followed up clinically for a mean of 6.23 months. No MACEs were noted. None of them had any Heart failure admissions. 1 subject died of noncardiac cause (respiratory failure due to COVID-19 pneumonia). 7 patients followed up angiographically after a mean follow up of 9.4 months. No significant ISR was noted in any of them. 1 subject underwent repeat target vessel revascularisation (TVR). Another subject underwent revascularisation to another vessel which was planned earlier. Conclusion: Coronary Intravascular lithotripsy (IVL) is a safe and effective method in the treatment of moderate to severe coronary calcific coronary artery disease which is safe and effective with good short-term and mid-term outcomes. However, the data is limited on long-term outcomes.

Implementation of a remote rapid access chest pain service during the COVID-19 pandemic

Background: Rapid Access Chest Pain Clinic (RACPC) is a vital service in many hospitals in the UK, providing early specialist input for patients with suspected coronary artery disease referred via the Emergency Department (ED) or primary care (1). When the COVID-19 pandemic forced hospitals to refine their outpatient systems (2), our Trust continued the RACPC service remotely via telephone consultations. Purpose: To examine the long-term viability of this service, we designed a study to compare the outcomes of patients seen remotely during the pandemic to patients seen face to face. Methods: We performed a retrospective cohort study. The remote group (n=217) were patients seen over 4 weeks in April 2020, all having telephone consultations. The control group (n=368) were patients assessed face to face in the same 4-week period in 2019. Outcomes being analysed included: mode of investigation;interventions performed;and a 12 month combined safety endpoint of ED attendance with chest pain, re-referral to cardiology and hospitalisation for cardiac issue. Subgroup analysis was performed based on typicality of symptoms defined by NICE (3). Results: Baseline characteristics were similar between groups. In both 2019 and 2020, the largest subgroup of patients were those with nonanginal chest pain (64%, 71%). There were significant differences in investigation and management between the two cohorts (Figure 1). In 2020, a higher proportion of patients were discharged with no investigation (57% vs 23%, p<0.0001). This was driven primarily by changes in management of patients with non-anginal chest pain. There were significantly higher rates of investigation of this subgroup in 2019 by either CT Coronary Angiography (25% versus 4.5%, p<0.001) or functional testing (25% versus 6.5%, p<0.001), with a much higher rate of reassurance and discharge in 2020 (81% versus 36%, p<0.0001). More patients received coronary intervention in 2019 than in 2020 (2.4% vs 0%, p=0.02). In 2020, higher proportions of patients were commenced on medical therapy without further investigation when presenting with atypical (28% versus 1%, p<0.0001) or typical angina (63% versus 11.4%, p<0.0001) (Figure 2). There was no significant difference in the 12 month combined safety endpoint (1.3% in 2019 versus 2.3% in 2020, p=0.39), and no reported cardiac deaths. Conclusions: During the pandemic, as expected, fewer patients were investigated for coronary artery disease, with the preference being to commence medical therapy initially. This did not have a significant effect on safety endpoints. Importantly, clinicians felt comfortable with assessing and discharging patients with non-anginal chest pain remotely in 2020. This is key to the viability of a remote RACPC model, as this subgroup forms the majority of the referrals. We suggest that RACPC is appropriate for a remote model in the long term, in view of the relatively low-risk population and clear management guidelines.

Different COVID19 pandemic phases & STEMI: experience from an Italian hub centre

Introduction and methods: During Coronavirus disease 2019 (COVID- 19) pandemic a reduction in ST-elevation acute myocardial infarction with an increase in in-hospital mortality has been observed. In our region the pandemic temporal trend was sinusoidal with peaks and valleys. A first outbreak (phase-peak 1 P-P1) was in March 2020 (248.12 cases for 100,000 inhabitants), a reduction (phase-valley 1 P-V1) in May 2020 (16.68 cases for 100,000 inhabitants) and a second outbreak (phase-peak 2 P-P2) in November 2020 (540.17 cases for 100,000 inhabitants;data from Italian Health Ministry). Our hospital was reorganized as one of the 13 Macro- Hubs identified in Lombardy for the treatment of STEMI. Here we describe our experience in the treatment of STEMI patients in the three different phases of COVID-19 pandemic. Results: In the three different phases the groups were superimposable for mean characteristics, but they differ for COVID-19 infection incidence (table). At multivariate analysis for the entire population COVID-19 infection (OR 45.8 [95% CI] 1.39-1511.79;p=0.03) was the only independent predictor of in-hospital mortality. Focusing on COVID-19 patients (figure) they experienced a 5-time increased incidence of in-hospital mortality (COVID- 19pos vs COVID-19neg, 50% vs 11.1%;p=0.02). Moreover, the compresence of COVID-19 infection induced an 8 times increased risk of death (OR 8;[95% CI] 1.85-34.60;p=0.005) determined by a higher incidence respiratory complications (COVID-19pos vs COVID-19neg, 33.3% vs 8.9%;p=0.03) with a similar incidence of cardiac death (COVID-19pos vs COVID- 19neg, 16.7% vs 11.17%;p=0.60). Conclusions: In conclusion our data suggest the crucial necessity of an early and precise diagnosis of COVID-19 infection in STEMI to establish a correct management of this very high risk patients. STEMI mortality in COVID+ vs COVID-.