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Introduction: Croatian National Cancer Registry of Croatian Institute for Public Health reported that in year 2020 lung cancer was the second most common cancer site diagnosed in men with 16% and the third most common in women with 10% incidence among all cancer sites. Unfortunatelly lung cancer has the highest mortality in both men and women. Haematological malignancies had 7% share in all malignancies in both male and female cances cases. In 2020 190 newly diagnosed cases of lymphatic leukemia in men and 128 cases in women were reporeted, meaning 1.5 and 1.2% of all malignancies, respectively. Chronic lymphatic leukemia (CLL) is an advanced age disease and incidence increases with age. Impaired immunity, T and B cell dysfunction in CLL, chromosomal aberations, long-term immunosuppressive therapy and genetic factors can all cause secondary malignancies. Co- occurence of solid tumors and CLL is very rare. Although patiens with CLL have an increased risk of developing second primary malignancies including lung carcinoma, the data about their clinical outcomes are lacking. Parekh et al. retrospectively analyzed patients with simultaneous CLL and lung carcinoma over a 20-year period, and they found that ~2% of patients with CLL actually developed lung carcinoma. The authors claimed that up to 38% of patients will also develop a third neoplasm more likely of the skin (melanoma and basal cell carcinoma), larynx (laryngeal carcinoma) or colon. Currently there are no specific guidelines for concurrent CLL and non-small cell lung carcinoma (NSCLC) treatment. Usually, when the tumors are diagnosed simultaneously, treatment is based to target the most aggressive malignancy, as the clinical outcomes depend on the response of the tumor with the poorest prognosis. For this reason, a multidisciplinary approach is mandatory. Case report: A patient with history of coronary heart disease, myocardial infarction and paroxysmal atrial fibrillation was diagnosed in 2019 (at the age of 71) with B chronic lymphocytic leukemia with bulky tumor (inguinal lymph nodes 8x5 cm), stage B according to Binet, intermediate risk. He was treated with 6 cycles of chemoimmunotherapy (rituximab/cyclofosfamid/fludarabine). In 10/2019 remission was confirmed, but MSCT described tumor in the posterior segment of upper right lung lobe measuring 20x17 mm and bilateral metastases up to 11 mm. Bronchoscopy and biopsy were performed, and EGFR neg, ALK neg, ROS 1 neg, PD-L1>50% adenocarcinoma was confirmed. He was referred to Clinical Hospital Center Osijek where monotherapy with pembrolizumab in a standard dose of 200 mg intravenously was started in 01/2020. Partial remission was confirmed in October 2020. Immunotherapy was discontinued due to development of pneumonitis, dysphagia and severe weight loss (20kg), but without radiologically confirmed disease progression. At that time he was referred to our hospital for further treatment. Gastroscopy has shown erosive gastritis with active duodenal ulcus, Forrest III. Supportive therapy and proton pump inhibitor were introduced. After complete regression of pneumonitis, improvement of general condition and resolution of dysphagia, no signs of lung cancer progression were found and pembrolizumab was reintroduced in 12/2021. Hypothyroidism was diagnosed in 01/2021 and levothyroxine replacement ther apy was started. In 03/2021 he underwent surgical removal of basal cell carcinoma of skin on the right temporal region with lobe reconstruction. From 02/2021, when pembrolizumab was reintroduced, regression in tumor size was continously confirmed with complete recovery of general condition. He was hospitalized for COVID 19 infection in 09/2021, and due to complications pembrolizumab was discontinued till 11/2021. Lung cancer immunotherapy proceeded till 11/2022, when Multidisciplinary team decided to finish pembrolizumab because of CLL relapse. CLL was in remission till August 2022 when due to B symptoms, lymphcytosis, anemia and generalized lymphadenopathy, hematological workup including biopsy of cervical lymph node was performed and CLL/SLL relapse was confirmed. Initially chlorambucil was introduced, but disease was refractory. Based on cytogenetic test results (IGHV unmutated, negative TP53) and due to cardiovascular comorbidity (contraindication for BTK inhibitors) venetoclax and rituximab were started in 01/2023. After just 1 cycle of treatment normal blood count as well as regression of B symptoms and peripheral lymphadenopathy occured, indicating the probability of complete disease remission. In our patient with metastatic lung adenocarcinoma excellent disease control is achieved during 41 month of treatment in first line setting. Furthermore, relapsed/refractory CLL/SLL is currently in confirmed remission. Conclusion(s): Successful treatment of patients with multiple primary malignancies is based on multidisciplinarity, early recognition and management of side effects, treatment of comorbidities with the aim of prolonging life, controlling symptoms of disease and preserving quality of life.
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The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.
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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: Among patients with COVID-19 infection, the risk of adverse cardiovascular outcome, particularly myocarditis and dysrhythmias remain elevated at least up to one year after infection. We present a case of atrial tachycardia and atrial Torsades de Pointes from COVID myocarditis, persisted 6 months after infection, which was successfully managed by ablation. Objective(s): A 25-year-old female presented with mild COVID-19 infection, Omicron variant, in May 2022. One month after, her Covid infection resolved;she presented with symptomatic atrial tachycardia, paroxysmal atrial fibrillation and flutter. ECG showed multiple blocked premature atrial contractions (PAC) (Figure 1A). Holter monitor showed PAC triggered atrial tachycardia degenerating to paroxysmal atrial fibrillation, atrial Torsades de Pointes. She has mild persistent troponin elevation. Echocardiography was normal. Cardiac MRI showed evidence of mild myocarditis with subepicardial late Gadolinium enhancement (LEG) along the lateral mid-apical left ventricular wall and edema. (Figure 1B). She was treated with Colchicine for 2 months. Repeat cardiac MRI 4 months after COVID infection showed resolution of edema and LGE. However, her symptomatic PAC and atrial tachycardia did not respond to betablocker and amiodarone. She underwent electrophysiology study. Activation mapping of PAC using CARTO revealed earliest activation at the right anterior atrial wall, with close proximity to tricuspid valve;unipolar signal showed QS pattern, bipolar signal showed 16 msec pre-PAC (Figure 1C and 1D). Mechanical pressure from ThermoCool SmartTouch ablation catheter (Biosense Webster Inc.) at this site suppressed the PAC. Radiofrequency ablation resulted with an initial acceleration and then disappearance of the PAC. We did not isolate pulmonary veins or ablate cavotricuspid isthmus. Post ablation, PAC and atrial fibrillation were not inducible on Isoproterenol. Method(s): N/A Results: Covid myocarditis can result in dysrhythmia that lingers long after Covid myocarditis has resolved. Covid myocarditis can be caused by direct viral invasion of myocytes or more commonly is inflammatory related to cytokine release and edema. Our case demonstrates that dysrhythmias can persist despite resolution of myocarditis. Catheter ablation can successfully to treat these arrhythmias. Conclusion(s): This case highlights the importance of recognizing cardiac dysrhythmia as possible the long-term cardiac complications of COVID-19, requiring specific treatment such as catheter ablation. [Formula presented]Copyright © 2023
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The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.
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Background: Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose(s): Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method(s): Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Result(s): 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as not significant (or not valid ). Compared to DGS, out of 108 valid strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusion(s): With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead.
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Current data indicate the existence of post-acute COVID-19 syndrome frequently expressing as cardiovascular and respiratory health issues. The long-term evolution of these complications is not yet fully known or predictable. Among the most common clinical manifestations of post-acute COVID-19 syndrome are dyspnea, palpitations, and fatigue, in most cases being transient and without underlying any morphological or functional changes. A single-center retrospective observational study was performed on cases that had presented with new-onset cardiac symptoms post-COVID-19 infection. Records of three male patients without pre-existing chronic cardiovascular pathology who had presented for dyspnea, fatigue, and palpitations around four weeks post-COVID-19 acute phase were studied in detail. The three post-COVID-19 cases exhibited arrhythmic complications after completely healing from the acute phase of the infection. Palpitations, along with chest pain, and possible aggravation or appearance of dyspnea, with syncopal episodes, were found to be present. All the three cases were non-vaccinated against COVID-19 infection. Isolated case reports showing arrhythmic complications such as atrial fibrillation and ventricular tachycardia on a small number of patients with these complications indicate the need for arrhythmic evaluation of large groups of patients in the post-acute stage of the COVID-19 syndrome for a better understanding of the phenomenon and implicitly better care of these patients. It would also be useful to evaluate large groups of patients divided into vaccinated/non-vaccinated against COVID-19 categories to determine whether vaccination per se can provide protection in the occurrence of these types of complications.
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Objective: To evaluate the need for cardiac monitoring of unselected patients recovered from COVID-19 and to estimate the risk of development of arrhythmias after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Result(s): Presence of significant pathology detected was rare (one paroxysmal atrial fibrillation in 73-year-old woman with dilated left atrium;71-year-old man with atrioventricular blockade with indication for implantation of the pacemaker, when cardiac MRI didn't find any signs of myocardial inflammation. After evaluation both were not related to previous SARS-CoV-2 infection. During one-year follow-up after COVID-19 infection there was no change in heart rate variability evaluated by SDNN (V1 vs V3 156.6+/-40.6 vs 156,0+/-38.0;p = 0.855), rMSSD (V1: 33+/-13.95 to 30.6+/-12.89;p = 0.175) and triangle (V1: 28.5+/-7.8 to 29.5+/-8.8;p = 0.488). Dividing heart rate oscillations into low-frequency (LF), and high-frequency (HF) bands, we have found statistically significant changes between V1 a V3 for LF (718+/-433.7 to 646+/-361;p = 0.024) and HF (341.5+/-335 to 268.0+/-266;p = 0.032). These parameters are mostly affected by breathing rate and are representing possible autonomic dys-regulation (HF/LF ratio). Conclusion(s): Despite many information regarding cardiac impairment of SARS-CoV2 our study does not suggest an increased risk of development of arrhythmias after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) even in a population with high proportion of ongoing symptomatology. Some findings may suggest autonomic dysfunction after COVID-19. Based on our results the routine ECG monitoring is currently not recommended after COVID-19 recovery.
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Introduction: Atrial fibrillation (AF) is one of the most common forms of arrhythmia in the clinic. There are about 10 million AF patients in China, of which 1/3 are paroxysmal AF, and the remaining 2/3 are persistent or permanent AF. Long-term AF impairs cardiac function and leads to heart failure and thromboembolism. Moreover, AF increases the risk of mortality and ischemic stroke. Drug therapy and radiofrequency catheter ablation (RFCA) are still the mainstream treatment for AF patients. However, drug therapy has its drawbacks because of the high recurrence rate and side effects. Therefore, the current antiarrhythmic drugs could not meet all the clinical needs of patients with AF. RFCA is superior to antiarrhythmic drugs in maintaining sinus rhythm, improving symptoms and exercise tolerance, and improving quality of life. The role of RFCA in the treatment of persistent AF has gradually been recognized and affirmed. Although RFCA has been progressively used in the treatment of AF, there is still a high recurrence rate of AF after RFCA, especially in patients with persistent AF. Hence, it is meant to solve the high recurrence rate of AF after RFCA. Shensong Yangxin (SSYX) capsule has been proven to treat arrhythmia both in animal studies and clinical research. SSYX capsule could regulate multi-ion channels, improve cardiomyocyte metabolism and regulate autonomic nervous function. In addition, randomized, double-blind, multicenter clinical research indicated that the SSYX capsule exhibited good clinical efficacy in treating ventricular premature beats and paroxysmal AF. However, the effect of SSYX on recurrence after RFCA for patients with persistent AF remains unclear. High-level randomized controlled trials (RCTs) could offer clinicians high-quality evidence regarding the usage of SSYX capsule, especially in persistent AF patients who received RFCA. Hence, the RCTs aim to evaluate the effect of SSYX capsules on the prognosis in patients with persistent AF after RFCA through multicenter, double-blind RCTs. Method(s): This trial will be conducted with a total of 920 participants diagnosed with persistent AF who received RFCA. The participants will be randomized (1:1) into groups receiving either SSYX or Placebo for 1 year. The primary endpoint includes the recurrence of AF within 1 year after RFCA. The secondary outcome measures include changes of AF load at 3 months, 6 months, 9 months, and 1 year after treatment, the time of first atrial flutter/AF, the incidence of cardioversion 1 year after treatment, changes of transthoracic echocardiographic parameters 1 year after treatment, the incidence of stroke and thromboembolism at 6 months and 1 year after treatment, the score of SF-36 within 1 year after treatment. Application: The trial is ongoing. The trial started in September 2019 and recruiting patients. Data collection will be completed after all participants have completed the treatment course and follow-up assessments (expected in 2022, pending COVID-19). Next Steps/Future: The SS-ADJUST study is a randomized control study of TCM in persistent AF after RFCA. It will determine the place of SSYX capsule as a new treatment approach and provide additional and innovative information regarding TCM and the specific use of SSYX in persistent AF after RFCA.
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Objectives: Considering the risk of aerosolization during the COVID-19 pandemic associated with transesophageal echocardiography (TEE), we evaluated the diagnostic performance of cardiac computed tomography (CCT) before pulmonary vein isolation (PVI) in comparison to semi-invasive TEE in excluding left atrial (LA)/LA appendage (LAA) thrombus, limiting the need for TEE to only patients with possible thrombus on CCT. Material(s) and Method(s): We included a total of 145 consecutive patients with atrial fibrillation (AF) (age 52.4 +/- 10.3 years;63% males;89 paroxysmal AF) referred for radiofrequency ablation in National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. All patients underwent preprocedural single-phase 128-slice multidetector CT and subsequent TEE as the reference standard with a mean time interval of 6.5 +/- 5.3 days between the two procedures. Result(s): CCT identified 30 patients (20.7%) with a filling defect in the LA/LAA, 8 of which were confirmed by TEE as thrombi (22 false positives and 8 true positives), whereas 9 true thrombi (6.2%) were detected by TEE (1 false negative by CCT). The sensitivity and specificity of CCT were 88.9% and 83.8%, respectively, with a positive predictive value of 26.8% and a negative predictive value of 99.1%. The overall accuracy was 84.1%. Conclusion(s): Apart from being a planned preparation modality before PVI, CCT is sufficient and could be used as an initial step to exclude the presence of LA/LAA thrombus, limiting the invasive TEE only for confirmation of the thrombus if detected by CCT.
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The lack of effective etiotropic therapy is a serious challenge in the treatment of patients with COVID-19. The recent emergence of a new class of medications neutralizing monoclonal antibodies against the SARS-CoV-2 spike protein allows to partially solve this problem. This article presents a clinical case of a patient with an increased risk of COVID-19 complications (paroxysmal atrial fibrillation, atherogenic dyslipidemia, impaired carbohydrate tolerance) who was treated with 600 mg casirivimab and 600 mg imdevimab by intravenous infusion. A significant improvement in the patient's well-being was noted within the first 24 hours: normalization of body temperature, stool, reduction of weakness, disappearance of arthralgia and myalgia. After 48 hours, a negative test result for SARS-CoV-2 RNA was obtained, which altogether made it possible to state the recovery. There were no adverse events during and after therapy. The casirivimab and imdevimab monoclonal antibody combination may be considered as a promising etiotropic treatment for COVID-19. Copyright © 2022, Dynasty Publishing House.
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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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SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Lazarus Phenomenon, also known as auto-resuscitation, is a rare event where cessation of CPR results in a delayed return of spontaneous circulation (ROSC). The phenomenon was named after the story of Lazarus, who was restored to life four days after death. We present a case of a 78-year-old male who presented to the hospital for septic shock and had intra-hospital cardiac arrest with ROSC after cessation of CPR. CASE PRESENTATION: 78 year old male with a medical history of paroxysmal atrial fibrillation, stage IIIA NSCLC and COPD, presented for progressive dyspnea. He complains of feeling weak with loss of appetite and had a recent mechanical fall. Initial vital signs were temperature 96F, BP 141/78, HR 75 bpm, RR 18/min, SaO2 100% on 2LNC. Initial labs showed lactic acid 11.6, BUN 55, creatinine 3.7, CO2 9, anion gap 25, AST 2654, ALT 2120, ALP 159, total bilirubin 0.8, troponin <0.1, CK 399, INR 4.2, PTT 36, WBC 16.5, Hb 10.8, and plt 202. COVID-19 testing was negative. CXR demonstrated a retro-cardiac opacity consistent with previous diagnosis of lung cancer versus a dense consolidation. He was started on antibiotics for sepsis and admitted to the ICU for his metabolic status and shock liver. He remained hemodynamically stable for a few hours until a he had sudden onset of unresponsiveness with asystole. Code blue was called. Repeat labs demonstrated lactic acid 15.5, potassium 6.3, CO2 9. He underwent resuscitation for 32 minutes when compressions were stopped. Within 5 minutes post arrest, sinus activity was noted on the cardiac monitor. The patient had a radial pulse on evaluation. Manual blood pressure measurement was 119/71 with a HR of 99. Arterial blood gas after ROSC showed a pH 7.0, pCO2 68, pO2 273, HCO3 16, lactic acid 19. A few hours later, the patient rapidly de-compensated and underwent resuscitation for a second time. Efforts were deemed futile and the patient expired. DISCUSSION: The physiologic description of the Lazarus phenomenon is yet to be fully elucidated. Hypotheses include auto-PEEP due to rapid manual ventilation generating increased intrathoracic pressure and decreased venous return, delayed drug effect and stunned myocardium during active chest compressions (1). Once chest compressions and positive pressure ventilation via manual bag-mask stops, sudden decrease in intrathoracic pressure allows for sudden venous return and re-perfusion of cardiac tissue, resulting in ROSC in some cases. A recent literature review cited 65 published cases over the past 30 years with the most common rhythm being asystole (2). Most cases of auto-resuscitation occurred between 5-10 minutes post stopping of chest compressions (2). Mortality of these cases were 70% post resuscitation (2). CONCLUSIONS: It is important for clinicians to be aware of the Lazarus phenomenon post resuscitative efforts and to observe patients carefully post resuscitation. Reference #1: Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. J R Soc Med. 2007;100(12):552-557. doi:10.1177/0141076807100012013 Reference #2: Gordon, L., Pasquier, M., Brugger, H. et al. Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med 28, 14 (2020). https://doi.org/10.1186/s13049-019-0685-4 DISCLOSURES: No relevant relationships by Vincent Chan No relevant relationships by Mackenzie Kramer No relevant relationships by Nathaniel Rosal No relevant relationships by Laura Walters No relevant relationships by William Ward
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Objective: The aim of the study was to compare the clinical particularities and the lab tests in hypertensive patients with metabolic syndrome, versus hypertensive patients without metabolic syndrome, admitted for SARS-COV2 infection. Design and method: We performed a retrospective study on 217 patients admitted to a Clinical Emergency Hospital between January 2021 and October 2021. Results: We had 217 patients admitted in internal medicine clinic for infection with SARS-COV2 virus. Patients with hypertension and metabolic syndrome (subgroup 1, 93 patients) were aged between 37 and 91 years (average age of 69 years). Patients with hypertension without metabolic syndrome (subgroup 2, 55 patients) were aged between 47 and 97 (average age of 72 years). Gender distribution in subgroup 1: 50% male, 50% female. In the subgroup 2, the gender distribution was: 51.52% male, 48.48% female. At admission, the stages of SARS-COV2 infection in subgroup 1, according to CT examination, were severe in 54.41%, moderate in 27.94%, and mild in 17.64%, and in subgroup 2 were severe in 47.16%, moderate in 24.52%, and mild in 28.30%. As comorbidities in subgroup 1: cancer in 5.88%, chronic heart failure in 26.47% of cases, atherosclerosis in 55.88%, COPD in 7.35%, depression in 7.35% and dementia in 5.88% of cases. In subgroup 2 the comorbidities were: cancer in 4.55% of patients, chronic heart failure in 36.36% of patients, atherosclerosis in 62.12%, COPD in 4.55%, depression in 3.03%, dementia in 10.61% of patients. High levels of the inflammatory markers in subgroup 1: CRP in 98.53% of cases, D-dimers in 85.29%, NT-proBNP in 76.34%, IL6 in 83.87%. In subgroup 2: high levels of CRP in 93.94% of cases, D-dimers in 84.85%, NT-proBNP in 69.09%, IL6 in 83.63%. Permanent atrial fibrillation was more prevalent in subgroup 2 (18.18% of cases) compared to subgroup 1 (9.67% of cases) while the prevalence of paroxysmal atrial fibrillation was higher in subgroup 1 (5.45% versus 8.60% of cases). Conclusions: Increased NT-proBNP and paroxysmal atrial fibrillation had a higher prevalence in patients with hypertension and metabolic syndrome for the same age group and degree of SARS-COV2 pulmonary infection.
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Background: We report a severe hypersensitivity reaction due to warfarin in a COVID19 patient with sepsis. Case Report: An 86-year-old man was admitted for COVID19 pneumonia. He was vaccinated with 2 ComirNaty doses. He was affected by hypertension and CKD in emodialysis. At the admission he presented fever and tachypnea, the laboratory tests showed a septic state. We started administration of empiric therapy with piperacillina/tazobactam, it was replaced with meropenem and linezolid on the 29th day. After 10 days linezolid was stopped for thrombocitopenia. On the 14th day we prescribed warfarin for tromboembolic risk prevention when paroxysmal atrial fibrillation occurred . At the fifth week there was a clinic and laboratory worsening so we started target antibiotic therapy with cefiderocol and colistin due to positive blood cultures for A. Baumanii XDR. On the 24th day an inguinal erytema with blister-like lesion occurred and involved progressively face, neck, limbs, trunk and abdomen with extensive skin sloughing and crusted lesions appeared in the perioral and perinasal mucosa. Nikolsky sign was negative. Skin biopsy showed signs of inflammatory reaction. Warfarin was stopped and 1mg/kg methylprednisone was started with slow and progressive benefit. Conclusions: The patient has developed a warfarin linked hypersensitivity reaction with clinical features similar to toxic epidermal necrolysis. We assume that it was a borderline condition of hypersensitivity to warfarin in a patient with hyperactivation of immune system due to COVID19 and sepsis.
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Background: Screening for atrial fibrillation (AF) is attractive because AF can remain undiagnosed and AF-related stroke can be prevented by anticoagulants (OAC). Methods: A randomized trial of screening for AF in individuals ≥70 years old without AF. Stroke and major bleeding are the efficacy and safety outcomes, ascertained from claims databases and electronic health records. Screening is done using a Zio®XT 14-day continuous cardiac rhythm patch monitor and compared, 1:1, to usual care. Use of OAC for detected AF is decided by patients and their physicians. The planned sample size was 52,000 recruited from U.S. primary care practices. Enrollment was severely hampered by the COVID-19 pandemic and stopped May 31, 2021 with 11,931 participants. Follow-up for stroke and bleeding events continues. Here, we report patch monitor findings from the 5,965 participants randomized to the screening arm. Results: 5,720 (96%) participants returned patches with analyzable data, the largest sample of patch monitor AF screening to date. Median (IQR) age was 75 (72, 79) years;57% were women. Median wear time was 13.9 (13.7, 14.0) days and median analyzable time was 98.4% (95.6, 99.5). 255 (4.5%) participants had AF, including 30 (0.5%) with 100% AF. 100% AF was more common in those age ≥80 (1.0%) than among younger participants (0.40%), p<.01. In the 225 participants with paroxysmal AF (PAF), median AF “burden” was 0.48% (0.016-2.5) of time monitored [78 (3.2, 454) minutes]. Median number of AF episodes during monitoring was 3 (1, 19). Median longest single AF episode was 60 (3-278) minutes. AF burden and length of longest episode were highly correlated (r=0.79, p<.001). Neither of these measures of PAF were associated with either age or sex. Conclusion: In GUARD-AF’s older primary care population, 0.5% of screened participants had persistent AF and 4% had PAF detected within 2 weeks of monitoring. In those with PAF, average AF burden was low but >25% had an episode of ≥4.6 hours of continuous AF, suggesting increased stroke risk. The need for stroke-preventive interventions (e.g., OAC) for screen-detected PAF remains a critically important research question.
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Background: Post-cardiac injury syndrome or Dressler syndrome, described as pericarditis with or without effusion, is often associated with myocardial infarction or a procedure in which the pericardium is disturbed. However, it may be provoked by a minor intervention, including radiofrequency ablation. Case: A 41 year-old male with paroxysmal atrial fibrillation (AF) and obstructive sleep apnea on CPAP presented with chest pain, palpitations, and dyspnea. He underwent cryoablation 1 month prior to presentation. He was febrile, tachycardic, and hypotensive. ECGs showed atrial flutter (Figure A) and AF with rapid ventricular response. Cardioversion was unsuccessful. Decision-making: Work-up included a negative COVID PCR. C-Reactive Protein was 311 mg/L (normal <10.0 mg/L). A CT chest showed bilateral pleural effusions and a pericardial effusion. Thoracentesis removed 850 mL of serous yellow fluid (exudative effusion). Transthoracic echo (TTE) revealed normal left ventricular function with a small pericardial effusion. Within 24 hours, the patient demonstrated tamponade physiology. Pericardiocentesis removed 400 cc of serosanguinous fluid.Cardiac MRI was concerning for myopericarditis (Figure B).Rate control for AF was difficult to achieve in the face of an inflammatory state. After several days of high-dose ibuprofen and colchicine, the patient started sotalol with conversion to normal sinus rhythm. Conclusion: Although rare, Dressler syndrome can be associated with minimally-invasive cardiac procedures, including cryoablation. [Formula presented]
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Case Report While the COVID-19 pandemic killing millions world-wide, definitive therapy is not yet available. However, vaccines were shown to effectively reduce COVID-19 related mortality. Side effects of COVID vaccination include thrombosis. Most of the vaccine-related thrombosis took place after the Oxford-AstraZeneca and Johnson & Johnson vaccines. Our case, however, developed thrombosis after receiving the Moderna mRNA vaccine. A 62 y/o female with hypertension and paroxysmal atrial fibrillation had retroperitoneal hematoma thought to be due to an aneurysm posterior to the pancreatic head and underwent embolization. Following this, she developed bilateral pulmonary embolism (PE) secondary to iliac vein thrombosis which was thought to be a direct result of compression from the hematoma. She was started on anticoagulation (rivaroxaban) at that time and monitored closely for possible bleeding. Unfortunately, she stopped rivaroxaban after one month due to financial reasons. A year later, the patient presented to the hospital with chest tightness for 3 days, one week after she took her 2nd dose of Moderna vaccine. 2 days later, she started having left-sided chest tightness and dizziness. She has no family history of clotting disorder, recent surgery, and has no known malignancy. On admission, she was hemodynamically stable with normal oxygen saturation in room air. Blood work showed normal platelet count and coagulation panel. CT angiogram of the chest showed PE in the right middle lobe segmental branch without right ventricular strain. She did not have troponin elevation or EKG changes. Apixaban was initiated through a financial assistance program on discharge. Although vaccine-related thrombosis remains at the top of the differential diagnosis for our patient, a history of prior thromboembolic event a year earlier and lack of adherence to anticoagulation may have enhanced this lady's resurgence of thrombosis. Having a high degree of suspicion following COVID vaccination is always important to make an early diagnosis and prevent serious consequences of thromboembolism. It is possible that the immune-modulatory effects of the mRNA vaccines can enhance the recurrence of thrombosis in persons with previous history of the condition.
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Objective: To evaluate the need for cardiac evaluation of unselected patients recovered from COVID-19. Methods: Prospective observational cohort study, which included 105 patients recently recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The diagnosis was established by reverse transcription polymerase chain reaction on swab test of the upper respiratory tract. Demographic parameters, patient history, clinical evaluation, cardiac blood markers, ambulatory 7-day ECG monitoring and echocardiography have been performed to determine possible cardiac injury. Results: The study group (n=105) included 58% women, mean age was 46 years (range 18-77 years). Mean time interval between the onset of the infection and the follow-up visit was 107 days. One quarter of the patients required hospitalisation during the acute phase of the disease, the rest recovered at home. 74% suffered from mild form, 3.8% moderate, 18.3% severe and 2.9% of critical form of the disease. At the time of evaluation 63.5% of the patients were referring the ongoing symptoms, fulfilling the criteria of postcovid syndrome, while more than half of the whole group mentioned at least one symptom of possible cardiac origin (breathing problems, palpitations, exercise intolerance, fatigue). One patient was diagnosed with paroxysmal atrial fibrillation (woman, 73 years old, dilated left atrium), one patient with atrioventricular block with indication for implantation of the pacemaker (man, 71 years, cardiac MRI didn't found any signs of myocardial inflammation);in one subject (man, 69 years) was diagnosed coronary artery disease due to atherosclerosis with the necessity of revascularization by percutaneous coronary intervention;one woman was prescribed beta-blocker for inadequate sinus tachycardia and palpitations. All these findings are not suspected to be the result of SARS-CoV-2 infection. In three patients mild pericardial effusion was found with no intervention necessary. There was not found any left or right ventricle dysfunction on echocardiography. Only three findings on ECG monitoring mentioned above need a therapeutic intervention. Conclusion: Despite the significant proportion of the patients with ongoing symptoms beyond the 12 weeks after the onset of the infection SARS-CoV-2, confirmed cardiac impairment is quite rare and distributed mostly among older patients and those with other risk factors.