Survival, ventricular arrhythmia, and implantable cardioverter-defibrillator usefulness in toxic cardiomyopathy due to substance abuse.

BACKGROUND: Toxic dilated cardiomyopathy (T-DCM) due to substance abuse is now recognized as a potential cause of severe left ventricular dysfunction. The burden of ventricular arrhythmias (VA) and the role of a prophylactic implantable cardioverter-defibrillator (ICD) are not well documented in this population. We aim to assess the usefulness of ICD implantation in a T-DCM cohort. METHODS: Patients younger than 65 years with a left ventricular ejection fraction (LVEF) < 35% followed at a tertiary center heart failure (HF) clinic between January 2003 and August 2019 were screened for inclusion. The diagnosis of T-DCM was confirmed after excluding other etiologies, and substance abuse was established according to the DSM-5 criteria. The composite primary endpoints were arrhythmic syncope, sudden cardiac death (SCD), or death of unknown cause. The secondary endpoints were the occurrence of sustained VA and/or appropriate therapies in ICD carriers. RESULTS: Thirty-eight patients were identified, and an ICD was implanted in 19 (50%) of these patients, only one for secondary prevention. The primary outcome was similar between the two groups (ICD vs. non-ICD; p = 1.00). After a mean follow-up of 33 ± 36 months, only two VA episodes were reported in the ICD group. Three patients received inappropriate ICD therapies. One ICD implantation was complicated with cardiac tamponade. Twenty-three patients (61%) had an LVEF ≥35% at 12 months. CONCLUSION: VA are infrequent in the T-DCM population. The prophylactic ICD benefit was not observed in our cohort. The ideal timing for potential prophylactic ICD implantation in this population needs further studies.

Heavy Burden of Toxic Dilated Cardiomyopathy Among Young Adults: A Retrospective Study and Review of the Literature.

BACKGROUND: Dilated cardiomyopathy (DCM) is a well described entity for heart failure (HF) with reduced left ventricular ejection fraction (LVEF). Recently, drugs and other substance of abuse have been recognised as potential triggers for DCM. The aim of this study was to assess the survival in patients ≤ 65 years of age with toxic cardiomyopathy (TCM). Left ventricular remodelling and the potential usefulness of left ventricular assist devices (LVADs) was also assessed. METHODS: This was a single-centre retrospective study from January 2003 to August 2019 of 553 patients ≤ 65 years old with LVEF < 40% at a tertiary-care cardiology centre. RESULTS: A total of 201 patients (36%) had a diagnosis of idiopathic DCM. Further analysis identified 38 patients (19%) for which a TCM was the most likely etiology (amphetamine [50%], cocaine [37%], anabolic steroids [8%], and energy drinks [5%]). Despite a mean LVEF of 17 ± 8% at presentation, most patients (n = 27; 71%) had event-free survival with guideline-directed medical therapy, and 61% (n = 23) recovered an LVEF ≥ 40% after a median follow-up of 21 ± 23 months. Seven patients (18%) required an LVAD and 1 patient (3%) a transplantation. All LVADs were explanted or decommissioned after partial or complete LVEF recovery after a median support time of 11 ± 4 months. CONCLUSIONS: TCM induced by substance abuse is a frequent cause of HF, accounting for almost 20% of patients ≤ 65 years of age with DCM of unknown etiology. Treatment must be tailored on an individual basis. Mechanical circulatory support demonstrated its usefulness in carefully selected patients.

Usefulness of Left Ventricular Assist Device in the Recovery of Severe Amphetamine-Associated Dilated Cardiomyopathy.

Exposure to synthetic drugs such as amphetamines may lead to significant consequences on the cardiovascular system. The prognosis of young adults with amphetamine-induced cardiomyopathy remains poor. We present 2 young patients (aged <40 years) who developed severe dilated cardiomyopathy after chronic amphetamine use. Thorough psychological evaluations demonstrated favorable features with patients being reliable and committed to their health problems. A left ventricular assist device (HeartMate II; Abbott, Chicago, IL) was implanted in the patients shortly after admission to optimize hemodynamic support and evaluate the potential for recovery. Within less than 1 year, significant improvement was achieved and successful explantation of left ventricular assist device was performed in both patients.

Do Energy Drinks Really Give You Wings? Left Ventricular Assist Device Therapy as a Bridge to Recovery for an Energy Drink-Induced Cardiomyopathy.

The deleterious effect of energy drinks is increasingly recognized. We present a 26-year-old woman with inotrope-dependent severe dilated cardiomyopathy, potentially caused by chronic ingestion of energy drinks. The results of extensive investigation-consisting of cardiac magnetic resonance, F-18-fluorodesoxyglucose-positron emission tomography, coronary angiography, and endomyocardial biopsy-were normal. A left ventricular assist device (LVAD) was implanted as a potential bridge to recovery. After 10 months of mechanical support and pharmacological treatment, cardiac function was recovered, and the LVAD was successfully explanted. This is the first case report of energy drink abuse leading to severe heart failure requiring mechanical support for recovery.

Atypical Presentation of Aspergillus Mediastinitis Infection in a Heart Transplant Patient: the Importance of Combined Medical and Surgical Treatment.

Aspergillus fumigatus is an opportunistic fungus that mainly affects immunocompromised patients. Due to significant immunosuppressive therapy, patients who undergo orthotopic heart transplant have an increased risk of infection. Aspergillosis is the most common fungal infection in orthotopic heart transplant recipients (70%) and usually presents as invasive aspergillosis, which has a rapidly progressive course and is highly fatal. In heart transplant patients with invasive aspergillosis, overall mortality may range from 53% to 78%. Aspergillus mediastinitis infection is somewhat rare in orthotopic heart transplant recipients, with only 6 reported cases. Treatment may require early surgical drainage and antifungal therapy. We present the case of a 50-year-old man who developed Aspergillus mediastinitis 1 year after heart transplant surgery. This case illustrates the diagnostic challenge of an atypical presentation of Aspergillus mediastinitis and the importance of multiple drainage procedures in refractory disease, combined with long-term antifungal therapy.

Management of Loeffler's Endocarditis With Bivalvular Involvement and a FIP1L1/PDGFRA-Negative Mutation.

Hypereosinophilic syndromes (HESs) are a group of disorders characterized by end-organ damage caused by eosinophilic infiltration. We present a patient with idiopathic HES with severe tricuspid and mitral regurgitation secondary to Loeffler's endocarditis. In addition to prednisone, imatinib therapy initially helped control the eosinophil count. However, successful long-term remission was achieved with hydroxyurea therapy.

Risk factors of mortality after surgical correction of ventricular septal defect following myocardial infarction: Retrospective analysis and review of the literature.

BACKGROUND: Rupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition. METHODS: We review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. A retrospective study was performed on 34 consecutive patients who had undergone surgical repair for VSDs following AMI from December 1991 to July 2014. Preoperative, clinical and echocardiographic variables were studied by uni-and multivariate analyses. RESULTS: Mortality was analyzed for the entire group of patients. Mean age was 69 ± 7 years with 44% women. VSDs were anterior in 11 (32%) and posterior in 23 (68%) patients. A majority, 24 (71%) patients were in cardiogenic shock. Median interval from myocardial infarction to VSDs repair was 7 days. The 30 days operative mortality was 65%. Mortality within the posterior VSDs group was 74% and the anterior VSDs group was 46% (P=0.14). Concomitant coronary artery bypass graft (CABG) did not influence early or late survival. Multivariate analysis identified older age (HR=1.11, P=0.0001) and shorter time between AMI and surgery (HR=0.90, P=0.015) as independent predictors of 30-day and long-term mortality. CONCLUSION: In conclusion, surgical repair of post-AMI VSDs carries a high operative mortality. An algorithm of treatment for the management of these patients is suggested.

Prevalence and Impact of Prosthesis-Patient Mismatch Following Surgical Aortic Valve Replacement for Pure Aortic Regurgitation.

BACKGROUND: Prosthesis-patient mismatch (PPM) is highly prevalent among patients undergoing aortic valve replacement (AVR) to treat aortic stenosis. Data regarding the prevalence and impact of PPM on left ventricular remodeling and outcomes in patients who have undergone surgical AVR to treat pure severe aortic regurgitation (AR) are, however, scarce. METHODS: A retrospective analysis was conducted of clinical and echocardiographic data acquired from 50 consecutive patients with pure severe AR, without evidence of significant coronary artery disease, who underwent AVR between 2004 and 2010 at the authors' institution. PPM was defined as a projected in vivo effective orifice area (EOA) 0.85 cm2/m2. RESULTS: The incidence of PPM was 16%, but no severe mismatch occurred. At a mean follow up of 52 ± 39 months, event-free survival (a composite of all-cause mortality and hospitalization for cardiovascular causes) was similar between patients with and without PPM (p = 0.73). Within seven days after surgery, mean reductions in indexed left ventricular end-diastolic diameter (LVEDD) and indexed left ventricular end-systolic diameter (LVESD) were similar between patients with and without PPM [4.4 mm/m2 versus 5.0 mm/m2; p = 0.67 and 1.6 mm/m2 versus 2.2 mm/m2; p = 0.35, respectively]. At follow up, no difference was observed for mean reductions in indexed LVEDD and indexed LVESD [6.9 mm/m2 versus 7.1 mm/m2; p = 0.91 and 4.1 mm/m2 versus 5.1 mm/m2; p = 0.57, respectively], and mean improvement in left ventricular ejection fraction (4.4% versus 5.1%; p = 0.87). CONCLUSIONS: PPM occurs less frequently in patients undergoing AVR for pure severe AR than for aortic stenosis, and seems to have a less significant impact on ventricular remodeling and outcomes.

Clinical Presentation and Value of Echocardiography in the Diagnosis of Freestyle Aortic Bioprosthesis Leaflet Tears: A Retrospective Study.

BACKGROUND: The unique design of the Freestyle stentless aortic bioprosthesis has led to different mechanisms of failure, particularly leaflet tearing. The aim of this retrospective study was to review the clinical presentation and echocardiographic data of symptomatic patients with leaflet tears and significant aortic regurgitation (AR) following implantation of the Freestyle bioprosthesis. METHODS: Between January 1993 and May 2011, a total of 430 consecutive patients was identified at the authors' institution who had undergone primary aortic valve replacement with a Freestyle stentless aortic bioprosthesis. Clinical and echocardiographic data were collected prospectively for all patients. Structural valve deterioration was the major cause of bioprosthetic valve failure. RESULTS: Twenty symptomatic patients presented with significant AR due to leaflet tears in the absence of more than mild valvular calcification. At presentation, all patients complained of dyspnea. Some 50% of patients (n = 10) presented with acute pulmonary edema, and 10% (n = 2) with cardiogenic shock. A leaflet tear was initially diagnosed using transthoracic echocardiography in five cases (25%), using transesophageal echocardiography (TEE) in eight cases (40%), or at surgery in seven cases (35%). An appropriate diagnosis of leaflet tearing was recognized at surgery in more than one-third of patients. Consequently, clinicians must be aware of the variety of clinical presentations and should have a high degree of suspicion regarding leaflet tears in patients who have received a Freestyle stentless aortic bioprosthesis and present with moderate to severe AR. CONCLUSIONS: For the optimal management of patients with Freestyle stentless aortic bioprosthesis and new moderate to severe AR, TEE should be considered in all patients.

The novel use of heart transplantation for the management of a case with multiple complications after acute myocardial infarction.

Rupture of the interventricular septum after myocardial infarction (MI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is usually the only definitive treatment for these patients because medical management is associated with a 30-day mortality approaching 100%. However with conventional surgical repair, operative mortality rates range from 33% to 53%. Furthermore, outcomes in patients with posterior ventricular septal defect (VSD) have been reported to have mortality rates up to 86%. Therefore, alternative treatment should be considered to improve management of this mechanical complication. We report the case of a 63-year-old man in whom VSD developed after an inferior MI. The patient presented with shortness of breath and a recent ST-elevation inferior MI. Transthoracic echocardiography revealed a 50% left ventricular ejection fraction with mild-moderate right ventricular dysfunction. A posterior VSD (diameter ≥ 12 mm), moderate ischemic mitral regurgitation (MR), and a posterior pseudoaneurysm were also seen. The operative risk was considered to be too high for VSD repair because the surgery would have to include bypass grafting, mitral valve replacement, and pseudoaneurysm correction. Consequently, an urgent heart transplantation was considered the best option. The patient underwent heart transplantation 9 days after initial symptoms, and the recovery was unremarkable. To achieve a definitive optimal treatment, we propose that patients with posterior VSD with significant MR or pseudoaneurysm, or both, should be considered as heart transplant candidates.