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Background Primary cardiac lymphoma (PCL) is an extranodal lymphoma involving only the heart and/or pericardium. PCL accounts for 2% of primary cardiac tumors and 0.5% of extranodal lymphomas. Its diagnosis is usually delayed due to rarity and non-specific findings. Case A 77-year-old man with Alzheimer dementia, atrial fibrillation on apixaban, and COVID-19 illness 3-weeks prior, who presented to the hospital with diffuse abdominal discomfort, fatigue, anorexia, and hypoactivity. Patient was tachycardic and normotensive with pronounced jugular venous distention, non-collapsing with respiration. ECG revealed sinus tachycardia, first degree atrioventricular (AV) block and chronic LBBB. Cardiac troponins were mildly elevated without significant delta. An abdominopelvic CT revealed an incidental, large pericardial effusion (PE). Bedside echocardiogram confirmed a large hemodynamically significant PE as well as a mass-like echogenicity encasing and infiltrating the pericardium and myocardium at the basal aspect of the right ventricle free wall. Decision-making In view of recent COVID-19 infection, he was started on indomethacin and colchicine for suspected viral or neoplastic pericarditis. Pericardiocentesis drained 900ml of amber to serosanguineous fluid with quick hemodynamic improvement. Fluid analysis was non-diagnostic for neoplasia. Subsequently, he developed symptomatic bradycardia with an intermittent complete AV block with junctional escape rhythm, transitioning to a second-degree AV block after removal of beta-blocker. Awaiting permanent pacemaker implant, he developed ventricular fibrillation with sudden cardiac death that required prolonged unsuccessful ACLS. Autopsy revealed an extensive infiltrative tumor, predominantly right-sided, consistent with primary cardiac B-cell lymphoma. Conclusion PCL should be part of the working diagnosis in patients presenting with a pericardial effusive process in combination with a right sided myocardial mass. Early cardiac MRI/PET scan or biopsy should be considered when the diagnosis is not certain. Prompt diagnosis could allow for treatment that potentially prolongs survival.Copyright © 2023 American College of Cardiology Foundation
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BACKGROUND: Coronavirus disease 2019 (COVID-19) may lead to myocardial damage and arrhythmia. Patients with ECG changes have shown an increased risk of mortality. OBJECTIVE(S): We aimed to study the changes in the electrocardiogram, which may be of great significance for risk stratification of COVID-19-positive patients. METHOD(S): A retrospective study was conducted to compare electrocardiogram changes and disease severity markers in COVID-19-positive patients admitted to a referral hospital between February 20 and March 20, 2020. RESULT(S): Our study consisted of 201 cases, including 123 males and 78 females. Ages ranged between 16 and 97 years old. Fifty-two (25.9%) cases had a history of ICU admission. Multivariate logistic regression analysis showed that a low O2 saturation level (OR = 0.920, 95% CI 0.868-0.976, p=0.005), several lab tests, ECG changes (OR = 46.84, 95% CI 3.876- 566.287, p =.002) and Age (OR = 1.03, 95% CI 1.000- 1.065, p =.048) were the independent risk factors for predicting mortality rate. In addition, we utilized multivariate logistic regression analysis, demonstrating that LBBB (OR = 4.601, 95% CI: 1.357-15.600, p=0.014) is the only ECG risk factor associated with morbidity in elderly patients with ECG changes. CONCLUSION(S): ECG changes are strong indicators of high mortality rates in elderly COVID-19 patients. ECG interpretations should therefore be used for risk stratification and predicting the need for ICU admission. Copyright © 2022, Isfahan University of Medical Sciences(IUMS). All rights reserved.
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Background and Aim: Malignant ventricular arrhythmia is an important cause of mortality in COVID-19 patients (1-3). In our study, we aimed to investigate the cardiac electrophysiological balance index (ICEB), which predicts the risk of malignant ventricular arrhythmia in patients with COVID-19 who developed SIRS (systemic inflammatory response syndrome). Method(s): After exclusion criteria (atrial fibrillation, left bundle branch block, pre-excitation), a total of 533 COVID-19 patients, of whom 197 (37%) were SIRS, were included in the study. Result(s): The average age in the study population was 62 (49-72), and the gender distribution was 49% (261) female, 51% (272) male. The patients were divided into two groups as the control group with SIRS and the control group without SIRS. The clinical, laboratory and demographic characteristics of the patients were compared in Table 1. The QTc/QRS ratio (ICEBc) in the SIRS group was 5.1 (4.64-5.1) and was significantly higher than 4.98 (4.5-5.45) in the control group (p=0.004). The QTc interval was 450 (422-474) and 427 (407-447) significantly longer in the SIRS group than the control group (p=0.001). As a result of multivariable linear regression analysis, a significant correlation was found between ICEBc and SIRS, age, gender and CRP. Conclusion(s): Malign ventricular arrhythmias developing in COVID-19 patients are an important cause of mortality. ICEBc and QTc were significantly higher in the SIRS group than in the control group. It was thought that ICEBc could be used to predict malignant ventricular arrhythmias in the patient group developing SIRS.
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Background and Aim: Chest pain is a one of the most common com-plaints in children admitted to the Hospitals. Although it was among the most common reasons for referral to the pediatric car-diologist before COVID-19 era, this tendency is changed during covid pandemic. The primary objective of this study was to inves-tigate the aetiological causes, clinical characteristics and the follow up symptoms in terms of changing habits of parents and children admitted to the ED for acute chest pain during pandemic. Method(s): We reviewed the medical records of children under the age of 18 who presented with chest pain as the chief complaint from 1 January 2020 to 1 April 2021, at Istanbul University-Cerrahpasa Pediatric Emergency Clinic retrospectively from the hospital data-base. The study population comprised 128 boys and 119 girls. Result(s): All the children underwent ECG examination. While the ECG results of 239 children were normal, 6 sinus tachycardia, 1 supra-ventricular tachycardia and 1 incomplete left bundle branch block were observed. 33 patients had an echocardiography. Eight patients with an abnormal Echo result already had been examined and diag-nosed prior to their emergency admission. Blood samples were taken from 48 children for troponin. 17 samples wereabove the cut-off value which was set to 0.004 g/dl A total of 32 SARS-Cov2 swab samples were taken from suspicious cases and analyzed with RT-PCR. Consequently, 8 of these children were Covid-19 positive. 7 patients had no history of chronic disease, while 1 patient had ALL. All of these patients had mild symptoms and none of them required hospitali-zation. The total number of children who were referred to a pediatric cardiologist for a further examination together with the follow-up patients of the pediatric cardiology department is 52 Conclusion(s): In conclusion, Chest pain is a common referral com-plaint in children and is rarely due to cardiac diseases. To date car-diac reasons of chest pain was the major concern of patients and families attending the ED. However we found that Patient/family concerns regarding 'vulnerability to the severe covid infection has emerged as an important discourse during the pandemic on attend-ences to ED because of chest pain.
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Background: With increasing utilisation of transcatheter aortic valve implantation (TAVI) for aortic stenosis, there is a need to explore the safety of next-day discharge. We aimed to evaluate the safety and outcomes of next-day discharge following TAVI. Methods: We performed a retrospective analysis of patients who underwent TAVI at a tertiary centre between 2020 and 2021. Included patients were those discharged the next day after TAVI as routine care. Data collected included baseline demographics, Society of Thoracic Surgeons (STS) score, perioperative complications and 30-day mortality rates. Results: Thirty-three patients (33% female, median age 82 years;interquartile range [IQR], 77–84) were discharged the next day post-TAVI. Median STS score was 2.3% (IQR, 1.7–3.6). On pre-TAVI ECG, two patients (6%) had right bundle branch block (QRS duration 147–154 ms). All patients demonstrated well-seated aortic valve prosthesis with no aortic regurgitation on same-day transthoracic echocardiogram. Six patients (18%) had new conduction abnormalities post-TAVI (five transient left bundle branch block, one atrial fibrillation which self-resolved). There were no significant procedural complications including no pericardial effusion or vascular injury. All patients were discharged directly home without the need for subacute care. Two patients (6%) were re-hospitalised within 30 days of discharge: one admitted with presyncope of unclear cause and one required a pacemaker for tachy-brady syndrome. All patients were alive and well at 30 days. Conclusion: We have demonstrated that next-day discharge TAVI is safe in selected patients with an uncomplicated procedure. In the era of COVID, implementation of next-day discharge can reduce unnecessary length of stay and may improve hospital resource allocation.
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Background: COVID-19 infection is known to damage myocardial tissue and increase arrhythmic events. However, the data in the literature on permanent attachments are limited. In our study, we planned to investigate possible arrhythmic damages in COVID-19 survivors using the frontal plane QRS-T [f(QRS)-T] angle and some other ECG parameters. Patients & Methods: 269 patients who recovered from COVID-19 between April 2020 and January 2021 were included into the study. Pre-admission electrocardiograms and first-month outpatient clinic control ECGs of the patients were compared. Results: After COVID-19, left bundle branch block (p<0.001), right bundle branch block (p<0.001), right bundle branch block (p<0.001), atrial fibrillation (p<0.001) rates had increased. Prolongation was detected in QRS duration (p<0.001), QT interval (p=0.014), adjusted QT interval (p =0.007) and Tpe interval (p=0.012). F(QRS)-T angle (p<0.001) and fragmented QRS rate (p<0.001) were increased. Conclusions: It was observed in our study that;even if patients survive after COVID-19, permanent deterioration in ECG parameters may occur.
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Case Report Learning Objective Recognizing Covid Myocarditis in Post covid syndrome Case Presentation A 56-year-old female with a medical history of hypertension and unvaccinated to COVID presented with sudden onset of chest pain radiating to the arm, 7/10 intensity aggravated with excretion, associated with palpitation and worsening bilateral leg swelling for last two weeks. She was recently tested positive for COVID infection four weeks ago. However, she did not seek medical treatment as she was asymptomatic at the time of infection. In the ER, she was diagnosed with A.Fib with RVR in hypotension needing two liters of oxygen and volume overload state with mildly elevated Troponin and EKG showing LBBB, grossly elevated BNP, all her inflammatory markers, and white cell counts within the reference range. She was admitted to ICU with cardiogenic shock needing two pressors and IV amiodarone. Urgent LHC was performed, showing normal coronary arteries with severely reduced EF of less than 20% with global hypokinesia on LV gram. Impella device was placed, and gradual diuresis with pressor support was administered. Overall hemodynamics improved, and pressors were weaned with continued aggressive diuresis. She improved well and was discharged with lifevest and an outpatient cardiology follow-up plan. Discussion The clinical features of myocarditis are usually non-specific, such as myalgias with a history of recent upper respiratory infection and typical age at onset varying between 20 to 50 years. New-onset HF over two weeks to three months with classical symptoms and non-specific changes EKG showing bundle branch block, atrioventricular (AV) block, or ventricular arrhythmias. Myocarditis should be suspected with or without cardiac signs and symptoms with elevated cardiac biomarkers, ECG changes suggestive of acute myocardial injury, arrhythmia, or global or regional abnormalities of LV systolic function, mainly if the clinical findings are new and unexplained. The clinical presentation of myocarditis is highly variable and can mimic other noninflammatory cardiac disorders;a high level of clinical suspicion is required. Conclusion We conclude that this new-onset HF with no evidence of acute coronary disease or any cardiac and familial risk factors with recent COVID infection makes us think that viral myocarditis is a possible cause of this acute presentation. Cardiovascular magnetic resonance (CMR) imaging is indicated in patients with suspected myocarditis if T2-based and T1- based imaging meet Lake Louise Criteria. Viral myocarditis should be an important consideration in patients with Covid- 19 and those who have recovered from even minor infections.
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Introduction: The connection of a number of inherited arrhythmias with febrile body temperature is proved. Due to connection between fever and clinical manifestations (including ECG changes) of inherited arrhythmias there are additional opportunities for diagnostics of these life-threatening arrhythmias in infectious patients (including Covid -19). Methods: 3584 ECGs of children with infectious diseases (average age 8.5±5.3 years old;boys - 57.5%, girls - 42.5%) were analyzed. Patients (pts) with QTc>440 ms or QTc<320 ms, complete right bundle branch block, left bundle branch block or its branches, atrioventricular block, ST elevation in the right precordial leads were given additional examination depending on the intended diagnosis (inherited arrhythmias): daily 12-channel Holter ECG monitoring, stress test, echocardiography. The family history was also clarified (cases of sudden cardiac death, syncope). The diagnosis was made on the basis of generally accepted diagnostic criteria and confirmed by molecular genetic analysis. Results: ECG changes, which are typical for Brugada syndrome (BrS), type 1, were detected in 2 pts (0.05%). Long QT syndrome (LQTS) was detected in 2 pts too. Mutations in the SCN5A gene (exon 16 Arg893Cys, R878H) were identified in pts with BrS and in the KCNQ1 (exon 9 Trp379Ter) with LQTS. In pts with LQTS, sinus tachycardia was registered with the background of increased body temperature, which allowed to reveal long QT interval. 1 pt with LQTS is a female athlete. 1pt with BrS had been previously observed by a cardiologist in connection with grade I atrioventricular block. An increase in body temperature leads to disruption of the sodium ion channels which underlie the development of the BrS. In the case of LQTS, in our study, the increase in the QTc is most likely due to a change in heart rate rather than a direct effect of an increase in body temperature on the ion channels. Conclusions: 1. BrS (type 1) was detected in 2 pts (0.05%) and LQTS in 2 pts (0.05%) at first. We consider that when taking an ECG from pts with fibril body temperature, this percentage may be higher. 2. ECG registration in pts with fever (including athletes) raises the probability of timely inherited arrhythmias diagnosis.
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Clinical Information Patient Initials or Identifier Number: BGS 22/0371940 Relevant Clinical History and Physical Exam: We present a case of an 80-year-old man with coronary risk factors diabetes, hypertension, dyslipidemia and familiarity without previous history of cardiac disease and known nephrolithiasis and urethral stenosis. He came to our observation during the second COVID wave pandemic within the emergency department for chest discomfort during hypertensive crisis and evidence of not known complete left bundle branch block and minimal elevation of TnI-HS levels. Relevant Test Results Prior to Catheterization: Echocardiography demonstrated septal dyskinesia with ejection fraction of 53%, no relevant valvular disease. The patient was hospitalized with the diagnosis NSTEMI for early coronary angiography within 24 hours and therapy according to the ESC 2020 NSTEMI Guidelines was initiated: acetylsalicylic acid 100 mg SID (no P2Y12 receptor inhibitors in unknown coronary anatomy), low molecular weight heparin atorvastatin 80 mg, ace-inhibitor, beta-blocker, rapid insulin and adequate hydration. Relevant Catheterization Findings: Angiography shoed critical mid RCA and ostial, LM (Medina 1.1.1) mid LAD and LCx stenosis (Fig.1). The patients definitively refused surgical revascularization choosing percutaneous one. At this point the mid (Fig.2.a.) and ostial RCA (Fig.2.b.) stenosis were fixed with DES with optimal angiographic and IVUS (Fig.2.c-d.) results. The left coronary system was studied with IVUS demonstrating significant LM/LAD/LCx stenosis and presence of circumferential calcification (Fig.3.a-b). [Formula presented] [Formula presented] Interventional Management Procedural Step: As a first step we performed rotational atherectomy on the axis LM-LAD (Fig. 3.c.) and LM-LCx (Fig. 3.d.) with 1,75 mm burr and after rewiring LAD (Renato) and LCx (Sion Blu) we repeated IVUS evaluation. Predilatation with non-compliant balloons of mid LAD and LCx and LM-LAD and LM-LCx (Fig.4.) was performed and then a bifurcation dedicated stent BIOSS was places on the axis LM-LCx (Fig. 5.a-b). The procedure continued with placing of a second DES in the mid LCx (Fig.5.c-d) and third DES in the mid LAD (Fig.6.a-b.). Then we placed a fourth DES (Fig.6.c-d.) in the axis LM-LAD (culottes with the just placed BIOSS on LM-LCx). Procedure was ended with DOT, POT, kissing balloon and final POT. Optimal result with IVUS (Fig.7.a-d) and angiography (Fig.7.e-f.) was achieved. The patient was discharged after 48 hours on DAPT and clinical follow-up was scheduled for 1st and 3rd month and angiography control after 6 months. [Formula presented] [Formula presented] [Formula presented] Conclusions: Adopting the common rules and guidelines in the everyday practice as in our case with NSTEMI patient rule-in/rule-out, early coronary angiography in less than 24 hours from admission, all vessels revascularization during index hospitalization, imaging in the left main treatment, stent like preparation of vessels before stenting and in some cases using of dedicated bifurcation stent can increase the success rate and reduce the complication rate.
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Introduction: Transcatheter aortic valve replacement (TAVR) has proven benefits in patients with reduced left ventricular ejection fraction (LVEF). A significant proportion of them shows recovery of systolic function Objective: To analyse the main baseline, electrocardiographic and echocardiographic characteristics that may predict LVEF recovery after TAVR. Methods: A cohort study was conducted. Consecutive patients undergoing TAVR in our center from January 2012 to December 2020 were included. Baseline clinical profile, electrocardiographic (EKG), echocardiographic (ECH) parameters were recorded, as well as MACE during followup (major adverse cardiovascular events including: all-cause mortality, myocardial infarction, cerebrovascular accident and heart failure hospitalization). Reduced systolic function was defined as LVEF <50%. We considered recovery of systolic function as LVEF ≥50% at follow-up. Results: A total of 292 patients were included. 48% were women and the median age was 81.07 years (77.63-86.22). 22.6% (66 patients) had reduced LVEF at baseline. Half of them showed recovered systolic function during follow-up. Patients who did not recovered LVEF had a higher prevalence of dyslipidemia and peripheral artery disease. History of cardiac surgery was more frequently found in this group, and they showed a higher surgical risk estimated by EuroScore II. They had lower LVEF and aortic valve mean gradient, and more frequently presented non-synus rhythm (NSR), left bundle branch block and right ventricular dysfunction (RVD). These characteristics are shown in figure 1. In univariate analysis lower Euroscore II, presence of synus rhythm, absence of LBBB and RVD, as well as higher aortic valve mean gradient were predictors of LVEF recovery. In multivariate analysis RVD and mean aortic gradient were independent predictors. Among all patients included in our study, those presenting with RV dysfunction were significantly associated with lower LVEF mean values (46,0% vs 57,2%;p<0,01) After a median follow-up of 21.3 (8.52-38.94) months, MACE were lower in recovered LVEF group (HR 0.25 95% CI: 0.05-1.21). There were no statistically significant differences in all-cause mortality, nevertheless there was a trend towards a higher non-cardiovascular mortality in this group, essentially at the expense of deaths from malignant neoplasms and SARS-COV- 2 infections. Survival curves for MACE are represented in figure 2. Conclusion: In our study, half of the patients with impaired ventricular function undergoing TAVR showed recovery of ejection fraction. Right ventricular function and aortic valve mean gradient at baseline were independent predictors of recovery. Identifying predictors of LVEF recovery is fundamental in the evaluation of potential candidates for TAVR, and can help clinicians assess risks and benefits, as well as long-term prognosis of these patients.