Paroxysmal Atrioventricular Block in a Relatively Young Patient with COVID-19.

Cardiac involvement has been reported in patients with coronavirus disease 2019 (COVID-19). We herein report a 41-year-old man who presented with recurrent paroxysmal atrioventricular block without showing significant cardiac injuries or comorbidities. The patient was diagnosed with COVID-19 and admitted to our hospital, where he was noted to have paroxysmal atrioventricular block. Cardiac biomarkers, echocardiography, and cardiac magnetic resonance imaging findings were fairly normal. An endomyocardial biopsy performed before the implantation of a permanent pacemaker revealed mild myocardial fibrosis without inflammatory infiltrates. The unusual myocardial involvement of the novel coronavirus was suspected.

Impact of first documented rhythm on cost-effectiveness of extracorporeal cardiopulmonary resuscitation.

OBJECTIVES: Recommendations for extracorporeal cardiopulmonary resuscitation (ECPR) state that appropriate patient selection is important for the sake of efficacy and cost-effectiveness of ECPR. It is not known whether first documented rhythm plays a prominent role in economic outcomes of patients with cardiac arrest who received ECPR. METHODS AND RESULTS: We reviewed the medical records of 120 consecutive patients who received extracorporeal membrane oxygenation (ECMO) assisted CPR due to refractory circulatory collapse between 2008 and 2016 in Urasoe General Hospital. The patients presented with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT; n = 59, 49.2%) or with asystole or pulseless electric activity (ASY/PEA; n = 61, 50.8%) as the first documented rhythm. Multivariate logistic regression analysis identified shorter duration from collapse to ECMO initiation (odds ratio, 1.95 per 10 min; 95% confidence interval, 1.32-2.89, p = 0.001), bystander CPR (odds ratio, 5.53; 95% confidence interval, 1.36-22.5, p = 0.017), and first documented rhythm of VF/VT (odds ratio, 3.93; 95% confidence interval, 1.30-11.8, p = 0.015) as clinical predictors for neurologically intact survival. Total hospital cost per life saved by ECPR for ASY/PEA was approximately twice that for VF/VT ($213,656 vs. $101,669). ECPR yielded Quality adjusted life years (QALYs) of 3.32 at a mean total cost of $39,634 for VF/VT and QALYs of 1.17 at a mean cost of $35,609 for ASY/PEA. The cost per QALYs was $11,081 for VF/VT and $29,447 for ASY/PEA. The incremental cost-effectiveness ratio of ECPR vs. conventional CPR was estimated to be $ 16,246 per QALY gained. CONCLUSION: ECPR for patients presenting with VF/VT was found to be highly cost-effective and ECPR for patients presenting with ASY/PEA was borderline cost-effective.

Outcome of prolonged balloon inflation for the management of coronary perforation.

BACKGROUND: Coronary perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention (PCI). OBJECTIVES: The purpose of this study was to review the cases of CP and to investigate the management after CP. METHODS: A total of 3469 PCIs were performed in our institution from April 1999 to April 2008. All CP cases were identified from our computerized database. RESULTS: Thirty patients were identified as having CP (0.86%). According to the Ellis classification, we determined the grade of perforation as type I in 17 cases (56%), type II in 2 cases (7%), and type III in 11 cases (37%). Most CPs were caused by wires (53%), while balloons, stents, and atherectomy devices were responsible for 7%, 37%, and 3%, respectively. Wire caused only 1 case of type III CP (6%), while stent caused 9 type III CPs (82%, p<0.01). Four patients (36%) with type III CP required urgent coronary artery bypass graft surgery (CABG), while no patient with type I/II CP required it (p<0.01). Prolonged balloon inflations were effective for 8 cases out of 11 stent CPs, however, the ballooning duration was significantly longer than that in wire and balloon CP (44±37min vs. 21±13min, p<0.05). CONCLUSIONS: Stent CP often causes type III CP and one third of type III CP required urgent CABG. Although stent CP required longer balloon inflations for the management, prolonged balloon inflation might be useful for the management even in the stent CP.

Quantitative assessment of dyssynchrony using ECG-gated SPECT myocardial perfusion imaging prior to and following cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) assists patients with advanced heart failure (HF) by improving left ventricular (LV) dyssynchrony, but there are significant numbers of non-responders, 1 reason being that the QRS duration is used as the only surrogate determinant of mechanical dyssynchrony, so an effective indicator of LV dyssynchrony is required. The present patient, who had HF, underwent CRT and showed clinical improvement with marked LV reverse remodeling. The regional contraction timing in the LV was assessed with software developed in an application on ECG-gated SPECT myocardial perfusion imaging that depicts the time-volume relationship of the segmented ventricular myocardium and the dispersion of time to end-systole as an expression of dyssynchrony. It was reduced in this patient following CRT. Discordance of systole in regional myocardial segments may present as mechanical dyssynchrony in the LV and could be used as an alternative to QRS duration. Quantitative assessment of dyssynchrony may be possible using this novel method, but further evaluation of the methodology is required.