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Introduction: Variants in PPP1R13L are associated with severe childhood-onset cardiomyopathy resulting in rapid progression to death or cardiac transplantation. PPP1R13L is proposed to encode a protein that limits the transcriptional activity of the NFkappaB pathway leading to elevated IL-1, IL-6, and TNF-alpha production in murine models. Optimal medical management for PPP1R13L-related cardiomyopathy is unknown. Here we report usage of a targeted anti-IL-1 immuno-modulatory therapy resulting in cardiac stabilization in a pediatric patient with congenital cardiomyopathy secondary to PPP1R13L variants. Case Report: A 4-year-old boy presented acutely with fever in the setting of persistent abdominal pain, vomiting, fatigue, and decreased appetite for two months following a mild COVID-19 related illness. Echocardiogram revealed severely depressed biventricular systolic function with an ejection fraction of 30%. Due to acute decompensated heart failure symptoms with hemodynamic instability, he was intubated and placed on continuous inotropic infusions with aggressive diuresis. Cardiac MRI demonstrated extensive subepicardial to near transmural fibrosis by late gadolinium enhancement in right and left ventricles. An implantable cardioverter-defibrillator (ICD) was placed due to frequent runs of polymorphic non-sustained ventricular tachycardia. Testing for viral pathogens was positive for rhino/enterovirus. Initial genetic testing was non-diagnostic (82-gene cardiomyopathy panel) but given the patient's significant presentation whole genome sequencing was pursued that showed two separate PPP1R13L variants in trans (c.2167A>C,p.T723P and c.2179_2183del,p. G727Hfs*25, NM_006663.4). Patient serum cytokine testing revealed elevations in IL-10 (4.7 pg/mL) and IL-1beta (20.9 pg/mL). Given the patient's tenuous circumstances and concern for continued progression of his cardiac disease, a trial of IL-1 inhibition via anakinra dosed at 3 mg/kg or 45 mg daily was initiated following hospital discharge. With approximately 6 months of therapy, the patient's cardiac function is stable with normalization of IL-10 and IL-1beta serum levels. Notably, the ventricular arrhythmia decreased after initiation of anakinra with no ICD shocks given. Therapy overall has been well tolerated without infectious concerns. Conclusion(s): In patients with PPP1R13L-related cardiomyopathy, immuno-modulatory therapies should be considered in an attempt to slow cardiac disease progression.Copyright © 2023 Elsevier Inc.
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Background: Aging and binge alcohol abuse are both known as independent risk factors for both atrial and ventricular arrhythmias. With the COVID-19 pandemic, increased social isolation has significantly increased alcohol consumption worldwide. Older adults are a high-risk drinking group and alcohol significantly enhances the risk of arrhythmia onset. Yet, how alcohol (a secondary stressor) drives spontaneous atrial and ventricular arrhythmia onset in the aged heart (a primary stressor) remains unclear. Objective(s): We recently reported the stress-response kinase c-jun N-terminal kinase 2 (JNK2) underlies alcohol-enhanced atrial arrhythmia vulnerability (pacing-induced) in healthy young hearts. Here, we reveal a critical role of JNK2 in alcohol-driven arrhythmia onset in the aged heart in vivo. Method(s): Ambulatory ECGs were recorded using wireless telemeters in binge alcohol-exposed aged (24 months) and young mice (2 months). Spontaneous premature atrial and ventricular contractions (PACs, PVCs), atrial and ventricular tachycardia (AT, VT) were quantified as previously described. The role of JNK2 in triggered arrhythmic activities was assessed using a well-evaluated JNK2-specific inhibitor and our unique cardiac-specific MKK7D and MKK7D-JNK2dn mouse models with tamoxifen inducible overexpression of constitutively active MKK7 (a JNK upstream activator) or co-expression of MKK7D and inactive dominant negative JNK2 (JNK2dn). Result(s): We found that binge alcohol exposure in aged mice (n=14) led to spontaneous PACs/PVCs (75% of the mice), and AT/VT episodes (50%) along with a 21% mortality rate. However, alcohol-exposed young (n=5) and non-alcohol-exposed aged mice (n=11) were absent of any spontaneous arrhythmic activities or premature death. Intriguingly, JNK2-specific inhibition in vivo abolished those alcohol-associated triggered activities and mortality in aged mice. The causative role of JNK2 in triggered arrhythmias and premature death was further supported by the high frequency of spontaneous PACs/PVCs and nonsustained AT/VT episodes along with a 50% mortality rate in MKK7D mice (n=10), which was strikingly alleviated in MKK7D-JNK2dn mice (n=5) with cardiac-specific JNK2 competitive inhibition. Conclusion(s): Our findings are the first to reveal that stress kinase JNK2 underlies binge alcohol-evoked atrial and ventricular arrhythmia initiation in aged mice. Modulating JNK2 could be a novel therapeutic strategy to treat and/or prevent binge drinking-evoked cardiac arrhythmias.Copyright © 2023
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Background: Viruses are the most common cause of myocarditis. With the ongoing COVID-19 pandemic, several cases of myocarditis have been reported in COVID-19 positive patients. Such patients may also experience a variety of arrhythmias that can provoke death. Objective(s): To evaluate the presence of various cardiac arrhythmias among COVID-19 positive myocarditis patients and understand their impact on mortality. Method(s): COVID-19 positive patients, admitted between April 1st 2020 to December 31st 2020, were recruited from the 2020 National Inpatient Sample. The presence of myocarditis and various cardiac arrhythmias were also identified via their respective ICD-10 codes. Logistic regression models were used to identify the odds of mortality in the presence of myocarditis. We further proceeded to estimate the odds of mortality among myocarditis patients who had various arrhythmias. Result(s): Our study found 6135 (0.4%) patients with myocarditis among 1628110 cases of COVID-19 recorded in the United States between April to December 2020. Age ranged between 0 - 90 years with a mean of 58 years. Multiple cardiac arrhythmias were also observed among myocarditis patients as 310 (5.1%) recorded supraventricular tachycardia, 520 (8.5%) had ventricular tachycardia, 120 (2.0%) had ventricular fibrillation, 520 (8.5%) had paroxysmal atrial fibrillation, 165 (2.7%) had atrial flutter, and 20 (0.3%) had long QT syndrome. The presence of myocarditis was linked with higher odds of mortality among all COVID-19 patients (aOR 2.551, 95% CI 2.405-2.706, p<0.01). Various cardiac arrhythmias were also potential predictors of mortality among myocarditis cases in COVID-19 patients, such as supraventricular tachycardia (aOR 1.346, 95% CI 1.041-1.74, p=0.023), ventricular tachycardia (aOR 1.896, 95% CI 1.557-2.308, p<0.01), ventricular fibrillation (aOR 4.161, 95% CI 2.74-6.319, p<0.01), and atrial flutter (aOR 1.485, 95% CI 1.047-2.106, p=0.026). Conclusion(s): Myocarditis was associated with higher mortality among COVID-19 admissions. Arrhythmias such as supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrial flutter were predictive of higher mortality in these patients. Continued caution is advised among health-care providers encountering these arrhythmias in myocarditis patients who are COVID-19 positive. [Formula presented] French language not detected for EMBFRA articles source xmlCopyright © 2023
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Background: Stereotactic radiotherapy (SBRT) is a new therapeutic option for patients with scar related ventricular tachycardia (VT). Objective(s): To describe our experience with the use of SBRT for the treatment of recurrent VT in patients with Chagas Cardiomyopathy (CCM) in whom catheter ablation is not an option. Method(s): We selected patients with Chagas Disease that underwent SBRT for recurrent VT treatment. The target sites of SBRT were planned based on CMR and CT reconstruction on ADAS software, bipolar voltage maps from previous CA procedures and VT morphology induced on a electrophysiologic study performed SBRT planning. Target sites were decided together by electrophysiology and radiation oncology group. Result(s): We performed SBRT in six CCM patients July 2021 to July 2022. Most patients were male (66.7%), mean age 62.3+/-5.7 years-old and EF 28.5% (Q1: 20 Q3:42.7). One patient (16.7%) had two prior catheter ablation, four (66.7%) had one and one patient had no prior ablation, but had severe pulmonary fibrosis after COVID and was O2 dependent. The mean PTV (planning target volume) was 85+/-14 mL and the ITV (internal target volume) was 29+/-4 ml, with safe constraints regarding the esophagus and stomach. In a mean FU of 244+/-173days, 3 (50%) patients presented VT recurrence after blanking period. Two patients died 86 and 50 days after SBRT. The median number of VT episodes reduced from 13 (6.25;44.75) to 7.5 (3;7.5) (P = 0.093). All alive patients stop presenting VT in a median period of 174 (Q1: 44.75: Q3: 199) days, being at the end of the follow-up in a median of 196 (Q1: 137;Q3: 246) days without new VT episodes. Conclusion(s): SBRT presents a high rate of early recurrence in Chagas disease patients that improves during timeCopyright © 2023
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Introduction: COVID-19 pandemic has resulted in more than 6.1 million deaths and more than 480 million infections worldwide (1). Left ventricular assist device patients (LVAD) with their multiple co-morbidities are at high risk for morbidity and mortality from the COVID-19 infection. Few studies and case reports demonstrating the outcomes of COVID-19 infection in LVAD patients have been published, with the most recent study in 2021 (2-4). However, none of these studies spanned the entire stretch of the pandemic. Hypothesis: : COVID-19 infection would result in significant mortality and multi-system complications among patients with an LVAD. Method(s): IRB approval was obtained for our retrospective cohort study. 225 LVAD patients across two large centers in Texas, USA were screened for COVID-19 infection from December 1, 2019 to February 28, 2022. 68 events of COVID-19 infection were identified among 64 patients. One patient was excluded due to false positive test and 3 patients were infected twice and counted as separate events. Outcomes including mortality, respiratory failure, bleeding, and thromboembolic complications were assessed. Result(s): Baseline characteristics and results are summarized in Table 1. 51% of the patients needed hospitalization or emergency department visit for COVID infection. Five patients were intubated (7.4%). 6 patients developed chronic hypoxic respiratory failure requiring outpatient supplemental oxygen. 4 patients suffered from ventricular tachycardias while three other patients had Implantable cardioverter Defibrillator (ICD) shocks during COVID infection. 9 patients had epistaxis or gastrointestinal bleeding within 1 month of testing COVID positive. One HM2 patient had confirmed LVAD outflow cannula thrombus on CT heart and another patient with HeartWare had confirmed inflow cannula thrombus requiring emergent exchange to HM3 due to pump stoppage. Three patients suffered a stroke (5%). No events of pulmonary emboli or DVTs were noted. The mortality rate among this cohort was 14% (9 out of 64 patients). Four patients died during the same hospitalization. 33% had HM2 and 67% had HM3 LVADs, making a mortality rate of 37% (3 out of 8) for HM2 patients and 9% for HM3 (6 out of 55). 88% were males, 56% were African Americans, 67% had NICM, and 78% had at least moderate RV dysfunction at baseline. Conclusion(s): COVID-19 infection resulted in significant mortality and complications including stroke, pump thrombus, arrhythmias, respiratory failure, and bleeding events among LVAD patients.Copyright © 2022
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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: Several studies described occurrence of myocarditis after SARS-CoV-2 vaccination in pediatric patients. Weaimed to characterize the clinical course of myocarditis following SARS-CoV2 vaccination including follow-up data within the prospective German registry for suspected myocarditis in children and adolescents "MYKKE." Method: Patients younger than 18 years with suspected myocarditis and onset of symptoms within 21 days followingSARS-CoV2 vaccination were enrolled within the MYKKE registry. The suspect of myocarditis is valid in patients with clinical symptoms and diagnostic findings typically seen in myocarditis. Clinical data are monitored at initial admission and duringshort-term and long-term follow-up. Result(s): Between July 2021 and August 2022, a total of 48 patients with a median age of 16.2 years (IQR: 15.2-16.8)were enrolled by 13 centers, 88% male. Onset of symptoms occurred at a median of 3 days (IQR: 2-7) after vaccine administration, most frequently after the second dose (52%). Most common symptoms at initial admission were anginapectoris (81%), fatigue (56%), dyspnea (24%) and documented arrhythmias (17%). Initial ECG abnormalities included ST-elevation (48%) and T-wave inversion (23%). Elevated Tropon in was observed in 32 patients (67%) and in 19 cases (40%)NT-proBNP was above the normal range with a median level of 171 pg/mL (IQR: 32-501). 11 (23%) patients presentedwith mildly reduced systolic function at initial echocardiography or cardiac MRI. In 40 patients cardiac MRI and/orendomyocardial biopsy was performed (83%) and diagnosis of myocarditis could be verified in 27 cases (68%). Thirty-nine patients underwent short-term follow-up with a median of 2.8 months (IQR: 1.9-3.9) after discharge. 19 patients (49%)presented with either clinical symptoms (n = 9) and/or diagnostic abnormalities (n = 16) at follow-up. 12 patients (38%)still had medical treatment. Except for one patient with malign arrhythmias (ventricular tachycardia), no major cardiac adverse events were observed during initial admission and follow-up. Conclusion(s): Our data confirm that SARS-CoV-2 vaccine-related myocarditis is characterized by a mild disease course. However, after short-term follow-up a considerable number of patients still presented with symptoms and/or diagnostic abnormalities. Data on long-term follow-up are awaited.
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Background: Both COVID-19 and the measures taken to control the pandemic may significantly affect cardiovascular health. The effects of a lockdown on physical activity and its potential consequences for arrhythmia burden remain largely unknown. Purpose(s): In this study, we investigated the effect of the lockdown during the first COVID-19 wave on patients' physical activity and arrhythmia burden. Method(s): All patients with an ICD connected to a Carelink homemonitoring system from two Dutch hospitals were included. Anonymized data on physical activity, heart rate, and occurrence of ventricular tachycardia/ fibrillation (VT/VF), and atrial fibrillation/tachycardia (AF/AT) were obtained and were compared between March-April 2020 (lockdown) and March-April 2019 (reference) within each patient. The study was approved by the local ethics committee. Result(s): The ICDs of 531 patients registered significantly less activity during de lockdown period compared to the reference period (210+/-104 min vs 182+/-103 min, p<0.0001, Figure 1, panels A and B), while weather conditions improved (1A). Daytime and nighttime heart rates were significantly lower during lockdown compared to the reference period (71.3+/-9 bpm vs 72.6+/-9 bpm, p<0.0001 and 63.4+/-9 vs 63.8+/-9, p=0.02, respectively). AF/AT burden increased (Figure 2A) while number of VT/VF episodes decreased (2B). There was no significant difference in number of NSVT episodes. Conclusion(s): During the lockdown in the first COVID-19 wave, the Carelink system revealed significantly less activity, increase in AF/AT burden and decrease in VT/VF episodes. Further investigation is needed to understand the relationship between physical activity and the occurrence of arrhythmias in ICD patients. (Figure Presented).
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Background: Kidney dysfunction is a prevalent disease that leads to many complications over time, such as hypertension, heart disease, and death. ACEI/ARBs are known to be renoprotective. However, few studies describe the association between ACEI/ARB use and kidney dysfunction in patients with SARS-CoV-2 infection. Purpose(s): To explore the association between patients with SARS-CoV- 2 and kidney dysfunction in patients taking an ACEI/ARB. We hypothesize a negative association between patients with SARS-CoV-2 taking an ACEI/ARB and kidney dysfunction. Method(s): A retrospective query between March 2020 and April 2021 was performed in patients 18 years and older who tested positive for SARSCoV- 2 using a polymerase chain reaction test. Patients were divided into two groups: Kidney dysfunction and no kidney dysfunction. Kidney dysfunction was defined as any diagnosis of chronic kidney disease or acute kidney injury. Primary outcomes were all-cause mortality and hospitalization rate. Secondary outcomes included myocardial infarction (MI), hypotension, intubation, vasopressor use, ventricular tachycardia, and ventricular fibrillation. We used multivariate logistic regression to adjust for baseline characteristics. Result(s): We identified 996 patients with kidney dysfunction and 22,106 without kidney dysfunction who tested positive for SARS-CoV-2. The incidence was 258 (25.9%) for ACEI/ARB use in patients with kidney dysfunction. Adjusted odds ratio (OR) for patients with kidney dysfunction was 5.705 (95% Confidence Interval [CI]: 4.554-7.146;p<0.001) for hospitalization, 0.895 (95% CI: 0.707-1.135;p<0.361) for patients taking ACEI/ARB, and 0.529 (95% CI: 0.333-0.838;<0.007) for mortality in patients with kidney dysfunction who took ACEI/ARB. All secondary outcomes had significantly greater adjusted OR (p<0.001), except for MI (p<0.339), ventricular tachycardia (p<0.697), and ventricular fibrillation (p<0.060). Conclusion(s): To date, the benefits of ACEI/ARB in SARS-CoV-2 patients have been controversial. While ACEI/ARB is known to have renoprotective properties, we did not find a significant association between ACEI/ARB and kidney dysfunction in patients with SARS-CoV-2. However, we found the use of ACEI/ARB in patients with kidney dysfunction to be associated with lower mortality. Therefore, clinicians should continue using this medication for its mortality benefits in patients with kidney dysfunction and its cardioprotective effects.
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Introduction: Early reports from China estimated that overall cardiac arrhythmia prevalence in patients hospitalized for COVID-19 was 17%. A higher arrhythmia incidence (44%) was observed in patients admitted to intensive care unit. The industrial workforce was affected by COVID-19 to a great extent. A noteworthy proportion also suffered from cardiac abnormalities. Objective(s): To determine the incidence of arrhythmia in patients with COVID-19 among the industrial workforce using remote patient monitoring technology. Material(s) and Method(s): This was a retrospective, observational, descriptive study of the industrial workforce from Telangana State, India. Approval of the institutional ethics committee was obtained. The need for informed consent was waived off. Patients who tested positive for COVID-19 by RTPCR and aged above 18 years were eligible. The five-day recording of lead-2 ECG on Vigo Monitoring Solution (Connect Care India Pvt. Ltd) was collected and analysed. Brady-arrhythmia during day time, second degree AV block Type-2 (Mobitz II) during the day time, complete heart block, wide QRST, non-sustained ventricular tachycardia and sinus pause were considered "clinically significant". The other sub-types were defined as "clinically non-significant". The ECGs with regular sinus rhythm were interpreted as "normal". The prevalence of clinically significant, clinically non-significant and normal heart rhythm are described here. Result(s): Out of 240 COVID-19 patients who were on-board for remote monitoring, 216 (148 male and 68 female, mean age 51+/-15 years) met the eligibility criteria and only their ECG were analysed. Among them, 18 were known diabetics, 40 were hypertensive and 31 had both comorbidities. 112 were asymptomatic and 104 were symptomatic. The burden of arrhythmia was found clinically significant in 12 (5.6%) patients, clinically non-significant in 87 (40.4%) and normal among 117 (54%) out of 216 patients. Conclusion and Recommendation: The remote patient monitoring may be utilized as a tool for early screening of significant arrhythmia which are to be addressed immediately for better clinical outcome. These devices on being integrated into COVID-19 management strategies may contribute to patient satisfaction, emergency alerts, timely management, reducing mortality rate and enhancing the safety of healthcare providers.
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Background Graft versus host disease (GVHD) most often occurs 100-365 days after hematopoietic stem cell transplant (HSCT). Manifestations most often are dermatologic, hepatic or pulmonic, and are rarely cardiac. We present a unique case of GVHD inducing cardiogenic shock necessitating advanced heart failure therapies. Case This is a 34 year-old male with a history of acute lymphoblastic leukemia who completed chemoradiation and HSCT from an HLA perfect sibling in 1992. In May 2020, he presented with dyspnea for 6 weeks. An echocardiogram at that time showed an EF of 10% and severe biventricular dilatation. He was originally hospitalized at an outside institution for hypoxia where a left heart catheterization showed normal coronaries and goal directed therapy was initiated. After 2 negative COVID tests, he was discharged with a LifeVest. One month later, despite medication compliance, he returned in cardiogenic shock after his LifeVest was activated for ventricular tachycardia (VT). Decision-making He was started on inotropic therapy and an intra-aortic balloon pump (IABP) was placed 1:1 prior to transfer to our tertiary center. After support was started, a right heart catheterization showed a right atrial pressure of 13 mmHg, a wedge of 17, and a cardiac index of 2.6. His course was complicated by VT storm. Differentials for his non-ischemic cardiomyopathy (NICMO) included myocarditis (viral vs. giant cell) with a possible component of chemotherapy/radiation induced NICMO. Immediate AHFT work-up was started. He was unable to be weaned off his IABP or inotropic support. The decision was made to pursue emergent left ventricular assist device placement (LVAD) and achieve a definitive diagnosis with a core biopsy. Pathology resulted with myocyte hypertrophy, chronic inflammation with eosinophils concerning for chronic GVHD. Conclusion There have only been a handful of case reports describing cardiac manifestations of GVHD, and none with NICMO and cardiogenic shock requiring an LVAD. Despite this, suspicion should remain present for GVHD in HSCT patients regardless of time frame from oncologic therapies or specificity of HLA match when presenting in cardiogenic shock.Copyright © 2023 American College of Cardiology Foundation
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Background The prevalence of anxiety and depression has increased following the COVID pandemic. Young women are disproportionally at risk of suicidal behaviors. Ingestion of Taxus baccata (English Yew) may lead to cardiotoxicity and death. Intoxication is known to be resistant to standard treatments with no effective antidotes. Case A 20-year-old female with a history of major depressive disorder presented to our emergency department unresponsive in pulseless ventricular tachycardia (VT) (figure 1A). She underwent CPR and achieved ROSC, however, was persistently hypotensive despite multiple pressors and was subsequently placed on VA ECMO. Review of a home journal revealed a plan to ingest 50 grams of Yew with suicidal intent. Decision-making Taxoids have been reported to have similar properties to digoxin and therefore digoxin-specific FAB antibodies were administered. She was also started on amiodarone and lidocaine for management of VT. After 3 hours she converted into sinus rhythm and had no further episodes of VT. Her clinical course was complicated by severe LV dysfunction and dilation while on VA-ECMO necessitating placement of an LV impella. By day three, all mechanical support was weaned off and she had normalization of her EF. Patient was discharged to an inpatient psychiatry facility on day 7 of hospitalization. Conclusion Ingestion of English Yew with suicidal intent is rare but may cause cardiogenic shock and VT requiring aggressive hemodynamic support until the toxin is metabolized. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Objectives: The study aims to determine the association between electrocardiographic abnormalities and in-hospital mortality of patients with Coronavirus Disease 2019 (COVID-19) infection admitted in a tertiary hospital in the Philippines. Material(s) and Method(s): We conducted a retrospective study of confirmed COVID-19-infected patients. Demographic, clinical characteristics, and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram (ECG) recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated. Result(s): A total of 163 patients were included in the study, most were female (52.7%) with a median age of 55 years old. Sinus rhythm (40%), nonspecific ST and T wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients and it was significantly associated with in-hospital mortality (p = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (p = 0.002), supraventricular tachycardia (SVT) (p = 0.011), ventricular tachycardia (p = 0.011), third-degree atrioventricular block (AVB) (p = 0.011), T wave inversion (p = 0.005) and right ventricular hypertrophy (RVH) (p = 0.011). Conclusion(s): The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. ECG abnormalities that were associated with mortality were atrial fibrillation or flutter, SVT, ventricular tachycardia, third-degree AVB, T wave inversion, and RVH. Supporting Documents Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection TARRANZA, Jannah Lee [1];RAMIREZ, Marcellus Francis [1,2];YAMAMOTO, Milagros [1] 1 Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines 2 Division of Electrophysiology, Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines.
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Ventricular tachycardia (VT) is a type of broad complex tachycardia originating from a focus in the ventricle. It is one of the four important rhythms which can lead to cardiac arrest. Accurate and timely diagnosis of true VT is the cornerstone for proper management in the emergency department (ED). We present an interesting case of an electrocardiographic artifact mimicking VT, which led to a diagnostic dilemma in the ED.Copyright © 2023 Rehman, Albaroudi, Akram, Ahmad, licensee HBKU Press.
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Coronavirus disease 2019 (COVID-19) has been reported to cause cardiovascular complications such as myocardial injury, thromboembolic events, arrhythmia, and heart failure. Multiple mechanisms-some overlapping, notably the role of inflammation and IL-6-potentially underlie these complications. The reported cardiac injury may be a result of direct viral invasion of cardiomyocytes with consequent unopposed effects of angiotensin II, increased metabolic demand, immune activation, or microvascular dysfunction. Thromboembolic events have been widely reported in both the venous and arterial systems that have attracted intense interest in the underlying mechanisms. These could potentially be due to endothelial dysfunction secondary to direct viral invasion or inflammation. Additionally, thromboembolic events may also be a consequence of an attempt by the immune system to contain the infection through immunothrombosis and neutrophil extracellular traps. Cardiac arrhythmias have also been reported with a wide range of implicated contributory factors, ranging from direct viral myocardial injury, as well as other factors, including at-risk individuals with underlying inherited arrhythmia syndromes. Heart failure may also occur as a progression from cardiac injury, precipitation secondary to the initiation or withdrawal of certain drugs, or the accumulation of des-Arg9-bradykinin (DABK) with excessive induction of pro-inflammatory G protein coupled receptor B1 (BK1). The presenting cardiovascular symptoms include chest pain, dyspnoea, and palpitations. There is currently intense interest in vaccine-induced thrombosis and in the treatment of Long COVID since many patients who have survived COVID-19 describe persisting health problems. This review will summarise the proposed physiological mechanisms of COVID-19-associated cardiovascular complications. Copyright © 2022, Anka Publishers. All rights reserved.
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Background: The COVID-19 pandemic resulted in a necessary transition from centre-based cardiac rehabilitation to virtual cardiac rehabilitation (VCR) to continue delivery of effective and high-quality care. To enhance risk stratification, an extended duration electrocardiographic (ECG) patch monitor was added to the intake protocol for patient's enrolled in a virtual only cardiac rehabilitation program. Method(s): The objectives of this study were to assess the diagnostic yield of extended ECG patch monitoring (DR400 3-channel monitor, NorthEast Monitoring, Inc., Maynard MA;5-day duration) and the effect on clinical management in a tertiary cardiac rehabilitation population. A retrospective analysis of consecutive patients enrolled in VCR at a single site was performed. All patients who were enrolled in VCR and underwent extended ECG patch monitoring as part of their intake assessment were included. Risk was defined by the AACVPR 2020 risk categorization. Extended patch monitor diagnoses were reviewed for accuracy and classified as a new or known diagnosis. Impact on clinical management was defined as any medication adjustment, procedure requirement/recommendation, or exercise prescription modification. Patient characteristics, cardiac testing results, and risk categorization were described using basic descriptive methods including frequency distributions, and means and SDs. Result(s): Two-hundred and sixty-nine patients [mean age 61.7 years (SD 12.0) 63% male] out of 286 patients enrolled in VCR between August 13, 2020 and October 26, 2021 met inclusion criteria (Table 1). Two percent of patients were classified as high risk, 41% as moderate risk, and 57% as low risk. Thirty (11%) new arrythmia diagnoses were obtained from extended ECG patch monitoring. Diagnoses included one patient with atrial flutter and high-grade AV block, one patient with paroxysmal atrial fibrillation, and 28 patients with non-sustained ventricular tachycardia (NSVT) (4-48 beats;11% symptomatic). Fifty-seven percent (n=17) of diagnoses were evident on the first 24-hours of monitoring and 43% (n=13) required extended duration monitoring for diagnosis. Thirteen patients with known atrial fibrillation or flutter were noted to have this arrhythmia present. Of those with a new diagnosis, 6 (20%) resulted in a change in clinical management (Figure 1). Conclusion(s): Extended duration ECG patch monitoring appears diagnostically and clinically useful when utilized as a component of intake evaluation for VCR. Furthermore, added benefit of extended (i.e., 5 day) versus the initial 24-hour period of monitoring was observed. Further evaluation is required to determine the optimal duration and clinical utility of asynchronous ECG monitoring as a component of risk stratification for VCR programs.
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Background and Aim: The European Medicines Agency has approved mRNA vaccines developed by Pfizer/BioNTech and Moderna for the vaccination of adolescents against the SARS-CoV-2 infection. Cases of myocarditis and pericarditis have been described as rare postvaccination complications. We describe the Latvian experience with adolescents suffering from myocarditis following COVID-19 vaccination. Method(s): From June to December 2021 four cases consistent with postvaccination myocarditis were admitted to the Children's Clinical University Hospital, which is the only centre with special-ized paediatric cardiology care in Latvia. The Pfizer/BioNTech vaccine had been used in all. An ECG, Holter monitoring and ECHO was done, HS Troponin I levels checked, the most common infectious causes of myocarditis were excluded, and a cardiac MRI was performed in all cases. Result(s): Case 1: 12-year-old girl, developed chest pain on postvac-cination day Nr 4 (PVD4) after the 1st dose. Holter monitoring revealed rare non-sustained ventricular tachycardia (NSVT), ECHO showed moderate mitral insufficiency, and a hyperecho-genic papillary muscle, troponin level peaked at 5339 pg/ml (PVD6), MRI (PVD 7) showed widespread myocardial oedema, transmural fibrosis. Symptoms resolved in 1 day, metoprolol suc-cinate and lisinopril were prescribed. Mitral insufficiency persists 5 months later. Case 2: 15-year-old boy, developed chest pain after the 2nd dose on PVD2 and lasted for 7 days, he was admitted on PVD11 with a peak troponin level of 19pg/ml. MRI (PVD15) showed widespread myocardial oedema. Metoprolol succinate was prescribed. Case 3: 15-year-old boy, developed chest pains on the day of the 1st dose and persisted for 35 days, he was admitted on PVD24 with peak troponin level 15ng/ml. MRI (PVD29) showed mild myocardial oedema, myocardial and pericardial fib-rosis. Case 4: 13-year-old boy, developed chest pain on PVD2, which lasted for 65 days, he had an episode of syncope. Holter monitoring showed frequent PVCs, and NSVT, on PVD34 tro-ponin level was 2,5pg/ml. The child received a course of NSAIDs and was referred to us on PVD68. MRI (PVD69) revealed wide-spread myocardial oedema, fibrosis, and pericarditis. Methylprednisolone was given, and betaxolol was prescribed. Conclusion(s): Our case series show that some cases of postvaccination myocarditis develop complications requiring long-term treatment.
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SESSION TITLE: Trainees: Mental Well-Being and Performance SESSION TYPE: Original Investigations PRESENTED ON: 10/16/22 10:30 am - 11:30 am PURPOSE: With the COVID-19 pandemic and hospital surges, our institution’s house staff was responsible for a significantly increased volume of critically ill patients while balancing residency training. In August 2020, a needs assessment survey was distributed among categorical Internal Medicine (IM) and Internal Medicine/Pediatrics (Med-Peds) residents. The results indicated low comfort levels in the evaluation of decompensating patients and in leading rapid response teams (RRTs). A grassroots initiative was started by two residents and a resuscitation nursing coordinator to address this need. Here, we describe the design and implementation of a resident-led simulation and clinical skills-based curriculum aimed at improving residents’ comfort in leading RRTs. METHODS: From August to September 2021, 56 senior level IM and Med-Peds residents attended a three-hour resuscitation workshop. A mixed educational format with high fidelity simulations, hands-on skills and small group debriefing discussions was implemented. Five scenarios were developed from retrospective hospital-wide RRT data;ventricular tachycardia (VT), supraventricular tachycardia (SVT), ventricular fibrillation, symptomatic bradycardia, and respiratory distress. Skills training included defibrillator use, transcutaneous pacing, adenosine administration, intraosseous line placement and low- and high-flow oxygen delivery devices. Participants were asked to complete a pre- and post-workshop questionnaire. The survey consisted of 7 questions about their comfort level on a 5-point Likert scale. A two-sample t-test was used to assess for difference in mean scores. RESULTS: Residents’ comfort level scores improved significantly in the following: from 3.49 to 4.36 (P< 0.0001) in the initial evaluation of an RRT patient, from 3.14 to 3.84 (P= 0.0026) in regard to thinking quickly during an emergency, and from 2.88 to 4.00 (P< 0.0001) in leading a RRT. There was also a global increase in comfort level scores with the scenarios: “VT” (P=0.0003), “SVT” (P< 0.0001), “symptomatic bradycardia” (P< 0.0001), and “respiratory distress” (P= 0.0324). CONCLUSIONS: Residents’ comfort levels as code leaders encountering various RRT scenarios significantly improved after our three-hour high-fidelity simulation and clinical skills workshop. CLINICAL IMPLICATIONS: Despite the challenges of COVID-19 group gathering restrictions and hospital surges, this training course became a well-received educational project to improve the effectiveness of resident-led RRTs. In response to its success, a pilot two-year curriculum involving more diverse RRT scenarios is currently being launched. The curriculum includes three workshop sessions per year for a multidisciplinary team of residents, pharmacy residents, and nurses aimed at improving code leader effectiveness and teamwork dynamics. DISCLOSURES: No relevant relationships by Tanja Barac No relevant relationships by Christie Brillante No relevant relationships by Lily Cheng No relevant relationships by Paul Cooper no disclosure on file for Cristina Diaz Pabon;No relevant relationships by Shaveta Khosla
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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: Pneumopericardium is the presence of air or gas in the pericardial space, usually secondary to blunt or penetrating trauma. Most pneumopericardium are non-tension. The use of positive pressure ventilation (PPV) increases the chances of developing a tension pneumopericardium. We report the case of a 22-year-old male patient admitted for COVID-19 pneumonia who developed pneumopericardium with cardiac tamponade features. CASE PRESENTATION: A 22-year-old male was admitted for acute respiratory distress syndrome due to COVID-19 pneumonia and required intubation on hospital day 10. The next day, he became febrile with new leukocytosis. A chest x-ray showed new extensive pneumomediastinum and pneumopericardium. Vasopressor support and broad-spectrum antibiotics were started for septic shock, however he continued to decompensate rapidly, requiring maximal medical support. His arterial line waveform showed pulsus paradoxus, leading to concern for underlying tension pneumopericardium. Bedside echo was unrevealing as imaging was obstructed by the air in pericardial sac. The patient was too unstable for a CT scan of the chest. After extensive discussion with his family, he was placed on palliative measures only and expired. DISCUSSION: Pneumopericardium is due to an abnormal connection between the pericardial space and a source of air or gas. Levin and Macklin describe three main mechanisms by which this connection can be made. The first: acute rises in alveolar pressure and volume or ventilator associated lung injury leading to rupture of alveoli with gas tracking along perivascular and peri bronchial sheaths to the mediastinum. The second: macro-perforation of the pericardial space leading to communication with respiratory or gastrointestinal tracts. Third: existence of a pneumothorax in the presence of traumatic pericardial tear or congenital pleuro-pericardial connection. Spontaneous pneumopericardium without any anatomic connection is rare and is due to a direct extension of infectious etiologies of the lungs or by an infection of the pericardial space with gas forming bacteria. A tension pneumopericardium causing cardiac tamponade can develop from pneumopericardium with PPV where the pericardial sac acts as a shutter valve letting air in but not out as has been reported sparingly in the literature. Cummings et al described 93 patients who developed tamponade out of 252 patients with pneumopericardium. Our patient possibly developed a pleuro-pericardial tract secondary to his pneumonia. With continued PPV his simple pneumopericardium likely developed into a tension pneumopericardium evidenced by arterial waveforms consistent with pulsus paradoxus, worsening hypotension despite maximal vasopressor support and development of ventricular tachycardia. CONCLUSIONS: Our case highlights the importance of considering pneumopericardium causing cardiac tamponade in the setting of mechanical ventilation. Reference #1: Mindaye ET, Arayia A, Tufa TH, Bekele M. Iatrogenic pneumopericardium after tube thoracostomy: A case report. Vol. 76, International journal of surgery case reports. 2020. p. 259–62. Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984 Jun;37(6):511–8. Reference #3: Levin AI, Visser F, Mattheyse F, Coetzee A. Tension pneumopericardium during positive-pressure ventilation leading to cardiac arrest. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):879–82. MACKLIN CC. TRANSPORT OF AIR ALONG SHEATHS OF PULMONIC BLOOD VESSELS FROM ALVEOLI TO MEDIASTINUM: CLINICAL IMPLICATIONS. Arch Intern Med [Internet]. 1939 Nov 1;64(5):913–26. Available from: https://doi.org/10.1001/archinte.1939.00190050019003 DISCLOSURES: No relevant relationships by Aarti Mittal No relevant relationships by Beenish Naqvi