Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis.

BACKGROUND: Calcific aortic stenosis is the principal indication for transcatheter aortic valve replacement (TAVR). Comorbid mitral annular calcification (MAC) is often present in patients undergoing TAVR. Limited data exist on the impact of MAC on TAVR outcomes. We conducted a systematic review and meta-analysis to explore the effects of MAC and concomitant mitral valve dysfunction (MVD) on TAVR outcomes. METHODS: A comprehensive literature review was conducted using PubMed, Embase, Google Scholar, ClinicalTrials.gov, Scopus, and OVID for studies until March 20, 2023. Using the random-effects Mantel-Haenszel method, we calculated pooled risk ratios (RRs) and their corresponding 95 % confidence intervals (CIs) for all dichotomous variables. RESULTS: Six studies comprising 5822 patients (2541 with MAC [severe MAC (>4 mm thickness) 583; non-severe MAC 1958; 400 with MVD; and 1071 without MVD], 3281 without MAC) met inclusion criteria. At 30 days and 1 year, no significant differences were observed between the overall MAC and no MAC groups in terms of mortality, stroke, and permanent pacemaker implantation. However, MAC with MVD was associated with a higher risk of all-cause mortality compared to MAC without MVD at 30 days (RR = 3.43, 95 % CI 2.04-5.76, P < 0.00001) and at 1 year (RR = 2.44, 95 % CI 1.85-3.20, P < 0.00001). Moreover, the risk of cardiovascular mortality was higher in patients with MAC and MVD compared to those with MAC alone (RR = 2.77, 95 % CI 1.89-4.06, P < 0.00001). Additionally, patients with severe MAC had a higher risk of major bleeding at 30 days compared to the non-severe MAC group (RR = 1.33, 95 % CI 1.04-1.69, P = 0.02). CONCLUSION: TAVR appears to be safe in patients with non-severe MAC, but severe MAC is associated with a higher risk of major bleeding and concomitant MVD increases the mortality risk in patients undergoing TAVR.

Left Coronary Artery to Pulmonary Trunk Fistula: Two Case Reports With Literature Review.

Coronary artery fistulas (CAFs) are abnormal communication between coronary arteries and the pulmonary trunk or with adjacent heart structures. Coronary pulmonary artery fistulas (CPAFs) can be congenital or acquired. Mostly, CAFs are found as incidental findings on angiographic evaluation. The management of CPAFs varies from case to case depending on size, anatomical location, patient's clinical presentation, and presence of coronary steal phenomenon. We present two cases of CPAFs; one of them had coronary steal phenomena at a young age with no past medical history of coronary artery disease, and the patient underwent transcatheter coil embolization to close the fistula. In other cases, a fistulous connection between the left anterior descending (LAD) and the pulmonary trunk was found incidentally on computed tomography (CT) of the heart and based on a small-sized fistula and symptomatic improvement, the patient was discharged with conservative management. CPAFs are rare cardiac anomalies but can give rise to severe hemodynamic complications, so this should be a part of the initial differential diagnosis if the patient does not have significant coronary artery disease. Percutaneous closure or surgical correction is indicated if the patients are symptomatic or have secondary complications.

Efficacy of Pemafibrate Versus Fenofibrate Administration on Serum Lipid Levels in Patients with Dyslipidemia: Network Meta-Analysis and Systematic Review.

BACKGROUND: Pemafibrate is a novel fibrate class drug that is a highly potent and selective agonist of peroxisome proliferator-activated receptor α (PPARα). We performed the first ever network meta-analysis containing the largest ever group of patients to test the efficacy of pemafibrate in improving lipid levels compared with fenofibrate and placebo in patients with dyslipidemia. METHODS: Potentially relevant clinical trials were identified in Medline, PubMed, Embase, clinicaltrials.gov, and Cochrane Controlled Trials registry. Nine randomized controlled trials met the inclusion criteria out of 40 potentially available articles. The primary effect outcome was a change in the levels of triglycerides (TG), high-density lipoproteins (HDL), or low-density lipoproteins (LDL) before and after the treatment. RESULTS: A total of 12,359 subjects were included. The mean patient age was 54.73 (years), the mean ratio for female patients was 18.75%, and the mean examination period was 14.22 weeks. The dose for pemafibrate included in our study was 0.1, 0.2, or 0.4 mg twice daily, whereas the dose for fenofibrate was 100 mg/day. Data showed a significant reduction in TG and a mild increase in HDL levels across the pemafibrate group at different doses and fenofibrate 100 mg group (with greatest effect observed with pemafibrate 0.1 mg twice daily). A mild increase in LDL was also observed in all groups, but the increase in LDL in the 0.1 mg twice daily dose group was statistically insignificant. CONCLUSION: Pemafibrate 0.1 mg twice daily dose led to highest reduction in TG levels and the highest increase in HDL levels compared with other doses of pemafibrate, fenofibrate, and placebo.

Myopericarditis Following the Third Dose of COVID-19 mRNA Vaccination: A Case Report.

Coronavirus disease 2019 (COVID-19) mRNA vaccine-related cases of pericarditis and myocarditis have been reported infrequently. Most of the patients usually present within a week of the vaccine, and on average, most of the cases were reported after the second dose of vaccine within two to four days. Chest pain was the most common presentation, and fever and shortness of breath were the other commonly reported symptoms. The patients can have positive cardiac markers and electrocardiogram (EKG) changes, and the cases can be mistaken for cardiac emergencies. We present a 17-year-old male patient with sudden onset substernal chest pain for two days who got the third dose of the Pfizer-BioNTech mRNA vaccine within 24 hours prior. EKG was remarkable for diffuse ST elevations, and troponins were elevated. Later, the cardiac magnetic resonance imaging confirmed the findings of myopericarditis. The patient was treated with colchicine and non-steroidal anti-inflammatory drugs (NSAIDs), completely recovered, and is doing fine to date. This case hights that post-vaccine myocarditis can be mistaken and early diagnosis and management can prevent unnecessary interventions.

A Coronary Cameral Fistula Associated With Incessant Ventricular Arrhythmias.

Coronary cameral fistula (CCF) is a rare congenital abnormality of abnormal communication between coronary arteries and cardiac chambers. Most patients are asymptomatic, while symptomatic patients are usually present in childhood. Adult patients can present with angina, heart failure, or arrhythmias. We report a rare case of CCF with associated recurrent torsade de pointes (TdP) in the absence of ischemic heart disease and electrolyte abnormalities.

Risk of Thromboembolism With Eltrombopag: A Case Report of Deep Vein Thrombosis and Bilateral Pulmonary Embolism.

Eltrombopag is a second-line therapy for refractory thrombocytopenia from immune thrombocytopenic purpura (ITP). The medication is generally well tolerated but can lead to adverse thromboembolic complications in rare instances. We present a case of lower extremity deep vein thrombosis with bilateral pulmonary embolism in an ITP patient receiving eltrombopag. The patient underwent catheter-directed thrombolysis for pulmonary embolism. Eltrombopag was stopped on discharge, considering the potential cause of venous thrombosis.

Management of Right Atrial Thrombus During MitraClip Implantation: A Case Report and Review of Literature.

Transcatheter mitral valve repair (TMVR) is a relatively novel approach for treatment of symptomatic severe mitral regurgitation. Intra procedural thrombus formation is a rare but potential complication. Herein, we describe a case of large right atrial thrombus formation after transseptal puncture, that was successfully managed using aspiration thrombectomy.

A CABG Complication - LIMA Graft to Cardiac Venous System Anastomosis Rescued by Percutaneous Coronary Intervention.

Inadvertent graft anastomosis to the great anterior cardiac vein is a known but rare complication of coronary artery bypass graft surgery (CABG). This is usually managed with percutaneous embolization of the inadvertently anastomosed graft with stenting of underlying atherosclerotic coronary artery disease (CAD) or by surgical correction. We present a similar case of the inadvertent left internal mammary artery (LIMA) graft anastomosis to the cardiac venous system, managed with the less complicated percutaneous coronary intervention of the underlying coronary artery disease due to anginal symptoms without the need for surgical correction or embolization of the graft.

Coil Embolization of a Left Anterior Descending Coronary Artery-Pulmonary Artery Fistula: A Case Report.

Coronary artery fistulas may be defined as abnormal connections between a coronary artery and either a heart chamber or the pulmonary artery. Although usually asymptomatic, they can become enlarged and rupture in rare instances, requiring prompt intervention. We present a case of a 66-year-old male patient with a left anterior descending-pulmonary artery fistula managed with coil embolization.

Role of point-of-care arterial blood potassium in diagnosing pseudohyperkalemia.

Hyperkalemia is a life-threatening emergency, but it needs to be differentiated from pseudohyperkalemia to avoid unnecessary treatment. We present a case of pseudohyperkalemia in a chronic lymphocytic leukemia patient with severe leukocytosis, highlighting the role of point-of-care potassium. Laboratory workup showed persistent hyperkalemia on analysis of venous blood samples even after treatment for hyperkalemia. Point-of-care potassium checks on whole arterial blood immediately after sampling were consistently in the normal range. Treatments for hyperkalemia were stopped to avoid life-threatening hypokalemia.

Impact of systemic lupus erythematosus on in-hospital outcomes of peripheral artery disease-insight from the National Inpatient Sample database.

Chronic inflammatory disorders like systemic lupus erythematosus (SLE) and rheumatoid arthritis are associated with worse outcomes in ischemic heart disease. However, there is a paucity of data regarding outcomes in patients with peripheral arterial disease (PAD) with concomitant SLE. The purpose of this study was to compare clinical features and in-hospital outcomes of PAD in patients with and without SLE from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample database. We performed a cross-sectional analysis on 520,665 patients diagnosed with PAD from quarter 4 of 2015 to 2017. The primary endpoint was risk-adjusted in-hospital mortality. Of the total patient population, 3080 patients (0.6%) had SLE compared with 517,585 controls (99.4%). The observed in-hospital mortality was higher in patients with SLE (6.3% vs. 4.6%, P < 0.001). To the best of our knowledge, this is the largest population-based study investigating the impact of SLE in patients with PAD. Our analysis showed higher in-hospital mortality in SLE patients than in those without SLE. Early diagnosis and aggressive management of SLE and its complications in these patients have the potential to improve overall outcomes.

Gemcitabine-Induced Thrombotic Microangiopathy Managed Conservatively in a Patient of Breast Cancer.

Thrombotic microangiopathy (TMA) consists of a group of occlusive microvascular disorders, which include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TMA can be classified as primary or secondary based on the etiology. Gemcitabine-induced TMA is a rare side effect of the drug with varying clinical presentations. We present a case involving the classic triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and renal failure associated with gemcitabine. Gemcitabine was immediately stopped, and our patient's condition improved with conservative management.

Covered Stenting for a Large Coronary Artery Aneurysm With Adjacent Stenosis in a Poor Surgical Candidate.

Coronary artery aneurysms (CAAs) are being increasingly diagnosed with the advent of coronary angiography, and their management depends on the clinical presentation, size, and etiology of the aneurysm. Small aneurysms are usually managed with covered stents, while surgical intervention is considered for large aneurysms. We present a challenging case of a large CAA with adjacent coronary artery stenosis managed with guide extension catheter-assisted covered stent deployment as the patient was not a good surgical candidate.

Comparison of In-Hospital Outcomes After Insertion of Watchman Device in Men Versus Women (from the National Inpatient Data).

Left atrial appendage occlusion with the Watchman device is approved to manage nonvalvular atrial fibrillation and prevent stroke in patients with contraindications to anticoagulation. This study aimed to analyze the National Inpatient Sample (NIS) data to evaluate gender disparities and further assess its impact on medical decision-making. The NIS data for 16,505 patients who underwent left atrial appendage occlusion with the Watchman device from 2016 to 2017 was used to perform a cross-sectional analysis. The primary end point was risk-adjusted in-hospital mortality. The study included 9,825 men and 6,680 women. Male patients were younger than female patients (mean age of 75.3 years vs 76.3 years, p <0.001). The observed in-hospital mortality was higher in female patients (0.3% vs 0.1%, p = 0.003). This remained significant after adjustment for baseline confounders (adjusted odds ratio 2.9, 95% confidence interval 1.4 to 6.3, p = 0.005). In conclusion, analysis of the large pool of NIS data reveals that female patients have relatively worse in-hospital outcomes in terms of mortality, length of stay, and total hospitalization cost than male patients who underwent Watchman device implantation. However, these disparities are not enough to impact the medical decision-making process and to defer the use of the Watchman device in female patients.

Deeply Inverted and Biphasic T-Waves of Wellens' Syndrome: A Characteristic Electrocardiographic Pattern Not To Forget.

Wellens' syndrome refers to specific electrocardiographic (ECG) abnormalities of deeply inverted T-waves in the precordial leads, mainly V1-V3, associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery. Identifying this specific pattern on the electrocardiogram is important as emergent treatment can prevent life-threatening myocardial infarction. We present a case of Wellens' syndrome that had a combination of inverted and biphasic T-waves patterns and where timely identification of the abnormal ECG pattern by the emergency physician and prompt intervention by the cardiology team prevented the development of myocardial infarction and hence permanent damage to the heart.

Portal Vein Thrombosis in a Patient With Methylenetetrahydrofolate Reductase Gene Mutation and Normal Homocysteine Levels.

A 21-year-old male presented with chief complaints of abdominal pain, nausea, and vomiting and was found to have portal vein thrombosis (PVT) on computed tomography (CT) scan of the abdomen, which was redemonstrated on ultrasound. Thrombophilia workup was negative except that patient was heterozygous for methylenetetrahydrofolate reductase (MTHFR) gene mutation. Homocysteine levels were normal. The patient was started on enoxaparin and discharged on apixaban with the plan to continue anticoagulation for at least six months. Follow-up MRI after four months showed interval improvement of the main portal vein thrombus with the use of Eliquis.

BRASH Syndrome Leading to Cardiac Arrest and Diffuse Anoxic Brain Injury: An Underdiagnosed Entity.

BRASH (bradycardia, renal failure, atrioventricular [AV] nodal blocking medications, shock, hyperkalemia) syndrome describes the phenomenon of profound bradycardia from a combination of hyperkalemia and use of AV nodal blocking medication with underlying renal injury. We present a case of BRASH syndrome in a patient on chronic beta-blocker therapy for his coronary artery disease who presented with life-threatening hyperkalemia and acute renal failure. Due to failure in early recognition and superimposed effect with further beta-blocker dosing, the patient developed profound bradycardia and later went into pulseless electrical activity cardiac arrest requiring cardiopulmonary resuscitation. Metabolic derangements and bradycardia later resolved with medical management, but unfortunately, the patient developed diffuse anoxic brain injury after the cardiac arrest and was declared brain dead.