A Rare Presentation of Myocardial Bridging With Heart Failure Symptoms.

Myocardial bridging is an under-recognized cause of angina. This congenital anomaly occurs when a segment of the epicardial coronary artery has a short intra-myocardial course. A significant intra-myocardial course may lead to ischemia, causing anginal symptoms. In this case report, we discuss a rare presentation of myocardial bridging with symptoms of heart failure. The pathology led to a marked degree of ventricular dysfunction and a significant drop in cardiac output (CO), and the patient had severe exertional dyspnea and functional limitations. The ischemic workup with diagnostic imaging and angiograms failed to explain the severity of symptoms, which were only evident in hemodynamic studies and cardiopulmonary exercise testing.

Long-Term Withdrawal of Anticoagulation and Antiplatelet Therapy in a HeartMate 3 Left Ventricular Assist Device.

A 73-year-old male with end-stage heart failure underwent insertion of the HeartMate 3 (Abbott, North Chicago, IL, USA) device. Systemic anticoagulation and antiplatelets were discontinued for 52 days due to postoperative bleeding. After hemorrhage resolution, we restarted warfarin monotherapy targeting an international normalized ratio of 1.8-2.5. Eight months later, there are no reports of pump thrombosis, thromboembolism, and bleeding.

Outcomes of Minority COVID-19 patients managed with ECMO: A single-center experience.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly burdened the global healthcare system since December 2019. Minority populations are found to have a higher incidence of hospitalization and higher mortality when compared to Caucasians. Extracorporeal membrane oxygenation (ECMO) is reserved for COVID-19 patients who develop respiratory failure refractory to conventional management. To our knowledge, no data has been reported on outcome differences between Minority COVID-19 patients and Caucasian COVID-19 patients managed with ECMO. We aimed to investigate the outcome differences between these two groups. METHODS: Our retrospective cohort study had 23 adults (aged 18 and older) diagnosed with COVID-19 by polymerase chain reaction. All patients developed acute respiratory distress syndrome (ARDS), refractory to conventional treatment, and were managed on ECMO support. The primary outcome of interest was mortality; the secondary outcome was the rate of ECMO-related complications. RESULTS: The overall mortality rate of our study was higher (70%) than other reports of the COVID-19 population on ECMO. Caucasians in our study had more severe respiratory acidosis with carbon dioxide retention and appeared to have a higher mortality rate of 85.7% compared to Minorities (62.5%). No differences in complication rates between these two groups were identified. CONCLUSIONS: Our cohort revealed a high overall mortality rate of COVID-19 patients on ECMO support. The Caucasian group was observed to have higher mortality than the Minority group. The high overall mortality was likely attributed to the Caucasian group, which had more severe respiratory acidosis before ECMO initiation, a known predictor of poor prognosis in ARDS patients. Our cohort's ethnic composition may also partially explain the high mortality rate since COVID-19 Minorities are reported to have worse outcomes than Caucasians. Larger and randomized studies are needed to investigate further the mortality and complication differences between Minority and Caucasian patients diagnosed with COVID-19 and managed by ECMO.

Acute-onset heart failure secondary to biventricular non-compaction cardiomyopathy and atrial septal defect in a woman presenting in the seventh decade.

We present a case of a previously asymptomatic 63-year-old woman who presented with worsening dyspnoea for 3 weeks. Initial transthoracic and later transoesophageal echocardiography confirmed biventricular non-compaction cardiomyopathy and a large secundum atrial septal defect (ASD) measuring 1.4 cm. Additionally, there was a haemodynamically significant left to right shunt causing acute decompensated systolic heart failure. She eventually underwent closure of the septal defect using a AMPLATZER Septal Occluder device. Decision to close the defect was made as the left to right shunt was causing severe pulmonary hypertension and acute heart failure. Since most heart failure treatments involve lowering of the LV afterload there was consideration that this could cause right to left shunting and could cause an Eisenmenger physiology. Hence the AMPLATZER Septal Occluder device was placed to eliminate the shunt through the ASD. The ASD combined with the non-compaction posed significant treatment challenge in this case.

Safety and feasibility of dopamine-atropine stress echocardiography.

BACKGROUND: Dobutamine-atropine stress echocardiography (DSE) has lower sensitivity in patients with advanced liver disease (ALD) due to vasodilation. HYPOTHESIS: Dopamine-atropine stress echocardiography (DopSE) may be an alternative to DSE in ALD patients by improving the blood pressure response to stress. METHODS: The safety and tolerability of DSE and DopSE were compared in 10 volunteers. The safety, adverse effects, and efficacy of DopSE were then assessed in 105 patients, 98 of whom had ALD. Dopamine was infused in stepwise fashion from 5 µg/kg/min to a peak dose of 40 µg/kg/min. Atropine was given before and in early stages of dopamine infusion up to cumulative dose of 1.5 mg. The hemodynamic responses of 98 ALD patients were compared with 102 patients with ALD who underwent standard DSE. RESULTS: In normal volunteers, systolic BP increased more with DopSE compared to DSE (61 ± 19 mm Hg vs 39 ± 15 mm Hg, P = .008). In 105 patients who underwent DopSE, none had adverse effects that required early stress termination. In the groups with ALD, the systolic BP increase (38 ± 28 mm Hg vs 12 ± 27 mm Hg, P < .001) and peak rate pressure product (RPP) (22 861 ± 5289 vs 17 211 ± 3848, P = <.001) were both higher in those undergoing DopSE versus DSE. The sensitivity and specificity of DopSE were 45% and 88%, respectively for coronary disease (≥70% stenosis) in 37 patients who had angiography. CONCLUSIONS: Dopamine-atropine stress echocardiography appears to be a safe stress modality and provides greater increases in RPP in patients with ALD compared to DSE.

A Rare Presentation of an Acute Type A Aortic Dissection Obscured Due to the Simultaneous Presence of Acute Pancreatitis.

Introduction: Acute pancreatitis (AP) and acute aortic dissection (AAD) are medical emergencies that must be promptly recognized to avoid the development of life-threatening complications. Both of these diseases can present with chest or epigastric pain which can radiate to the back, thus, early suspicion based on clinical presentation and risk factors is essential. We present the case of a 56-year-old patient initially diagnosed with AP who was later found to have an AAD. Clinical Findings: A 56-year-old man with a history of alcohol abuse presented with 1 day of diffuse abdominal pain, nausea and vomiting. His lipase was 3,909 U/L and creatinine was 2.19 mg/dL and he was diagnosed with acute alcoholic pancreatitis with acute kidney injury. A non-contrast computed tomography (NCCT) scan of the abdomen showed aortic calcifications. He received 3.8 liters of fluids after which he developed acute respiratory distress requiring intubation. A workup for extracorporeal membrane oxygenation (ECMO) was initiated, given the suspicion of acute respiratory distress syndrome (ARDS) due to pancreatitis. This revealed an AAD with severe aortic regurgitation on transthoracic echocardiography (TTE). CT angiogram showed type A AAD involving the aortic root, ascending aorta, descending aorta, suprarenal and infrarenal abdominal aorta. The celiac axis, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) were patent. Outcomes: The patient underwent type A AAD repair with mechanical aortic valve replacement and survived the acute event. His AP resolved and he was discharged home with appropriate follow up. Conclusion: We hypothesize that if our patient was not assessed for ECMO, the finding of AAD would have been a diagnostic challenge. AP secondary to AAD is rare but a high index of suspicion is required for diagnosis.

Impella to unload the left ventricle in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND AND AIM: Impella is frequently used to unload the left ventricle in patients with cardiogenic shock on venoarterial extracorporeal membrane oxygenation (VA-ECMO). There is limited data regarding the use of this strategy. This study aims to evaluate the safety and efficacy of the said strategy. METHODS: A systematic search for studies comparing Impella plus VA-ECMO (ECVAD) vs VA-ECMO alone was performed using Pubmed, Cochrane Library, and Scopus. Studies meeting inclusion criteria were then used to perform a meta-analysis. RESULTS: Three studies involving 448 patients were included in the final analysis. In total, 117 (26%) patients were female, mean age was 57 years. VA-ECMO was placed in 355 out of 448 (79%) patients, while ECVAD was placed in 93 out of 448 (21%). Death occurred in 49 out of 93 (52.6%) patients on ECVAD and 226 out of 355 (63.6%) on ECMO, relative risk (RR): 0.76, confidence interval (CI), 95% (0.62-0.94) P = .01. Hemolysis was present in 46 (49.4%) patients in the ECVAD vs 67 (18%) in the ECMO group, RR: 2.64, CI, 95% (1.97-3.55) P < .01. Bleeding was present in 42 (45.2.%) patients in the ECVAD group and 135 (38%) in the ECMO group, RR: 1.25, CI, 95% (0.95-1.63) P = .11. CVVHD was used on 31 (33.3%) patients in the ECVAD group while 89 (25%) in the ECMO group, RR 1.35, CI, 95% (0.95-1.91) P = .10. CONCLUSION: This study suggests that the use of Impella as an unloading strategy in patients with VA-ECMO decreased mortality, increased rate of hemolysis, neutral bleeding risk, and similar rates of acute kidney injury requiring CVVHD.

Importance of a Risk Stratification Strategy to Identify High-risk Patients Presenting With Cocaine-associated Acute Coronary Syndrome.

OBJECTIVE: Current guidelines recommend treating patients with cocaine-associated chest pain, unstable angina, or myocardial infarction similarly to patients with traditional acute coronary syndrome (ACS). Risk stratifying these patients could potentially reduce unnecessary procedures and improve resource utilization. METHODS: This is a retrospective cross-sectional analysis of 258 patients presenting with cocaine-associated ACS who underwent cardiac catheterization in a community teaching hospital between 2006 and 2015. The primary outcome was the prevalence of acute obstructive coronary artery disease (CAD) requiring percutaneous coronary intervention and coronary artery bypass grafting compared with that of patients with normal coronary or nonobstructive disease. RESULTS: Of the studied population, 36% had obstructive CAD requiring intervention and 64% were found to have normal coronaries or nonobstructive disease. Significant risk factors for obstructive CAD were older age, history of CAD, diabetes mellitus, dyslipidemia, ST-segment-elevation myocardial infarction, and troponin elevation. A logistic model was developed based on these variables, applied to the studied population, and was found to have 93% sensitivity in predicting the likelihood of obstructive CAD. CONCLUSIONS: Cardiac catheterization in patients presenting with cocaine-associated ACS may be overutilized. A predictive model based on clinical risk factors may help individualize patient care and reduce unnecessary invasive diagnostic interventions.

Devices and interventions for the prevention of adverse outcomes of tachycardia on heart failure.

Heart failure (HF) is the leading cause of hospitalization in the USA. Despite advances in pharmacologic management, the incidence of HF is on the rise and survivability is persistently reduced. Sympathetic overdrive is implicated in the pathophysiology of HF, particularly HF with reduced ejection fraction (HFrEF). Tachycardia can be particularly deleterious and thus has spurred significant investigation to mitigate its effects. Various modalities including vagus nerve stimulation, baroreceptor activation therapy, spinal cord stimulation, renal sympathetic nerve denervation, left cardiac sympathetic denervation, and carotid body removal will be discussed. However, the effects of these modalities on tachycardia and its outcomes in HFrEF have not been well-studied. Further studies to characterize this are necessary in the future.

A case of electromagnetic interference between HeartMate 3 LVAD and implantable cardioverter defibrillator.

Implantable cardioverter defibrillators (ICDs) have been shown to have a significant benefit in reducing sudden cardiac death (SCD) in patients with systolic heart failure. Additionally, cardiac devices as a bridge to transplant or destination therapy are often used in patients with end-stage systolic heart failure. As a result, most patients with left ventricular assist devices (LVADs) also have an ICD. Here, we present an electromagnetic interference (EMI) between HeartMate 3 LVAD and ICD. This issue might be critical for both electrophysiologists and advanced heart failure cardiologists to understand prior to implantation of ICD/LVADs in these patients.

FOLFOX Induced Takotsubo Cardiomyopathy Treated with Impella Assist Device.

Chemotherapy induced cardiotoxicity is becoming increasingly prevalent with several new agents being used recently. The incidence of Takotsubo cardiomyopathy due to 5-fluorouracil based chemotherapeutic regimens like FOLFOX is not uncommon. It is also seen with platinum based chemotherapy. Most of these patients have reversible cardiotoxicity and the cardiac function recovers within a short period with supportive treatment. Here we have a patient who presented with cardiogenic shock after 5 days of receiving FOLFOX regimen for colorectal adenocarcinoma. She was treated with a percutaneous left ventricular assist device, Impella CP, for hemodynamic support with excellent outcome.

Medical and surgical treatment of acute right ventricular failure.

Acute right ventricular (RV) failure is a frequent and serious clinical challenge in the intensive care unit. It is usually seen as a consequence of left ventricular failure, pulmonary embolism, pulmonary hypertension, sepsis, acute lung injury or after cardiothoracic surgery. The presence of acute RV failure not only carries substantial morbidity and mortality, but also complicates the use of commonly used treatment strategies in critically ill patients. In contrast to the left ventricle, the RV remains relatively understudied, and investigations of the treatment of isolated RV failure are rare and usually limited to nonrandomized observations. We searched PubMed for papers in the English language by using the search words right ventricle, right ventricular failure, pulmonary hypertension, sepsis, shock, acute lung injury, cardiothoracic surgery, mechanical ventilation, vasopressors, inotropes, and pulmonary vasodilators. These were used in various combinations. We read the abstracts of the relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for any additional relevant papers. This review summarizes the general measures, ventilation strategies, vasoactive substances, and surgical as well as mechanical approaches that are currently used or actively investigated in the treatment of the acutely failing RV.

"Pseudo" Faraday cage: a solution for telemetry link interaction between a left ventricular assist device and an implantable cardioverter defibrillator.

Patients implanted with left ventricular assist devices (LVAD) may have implantable cardioverter defibrillators (ICD) implanted for sudden cardiac death prevention. This opens the possibility of device-device communication interactions and thus interferences. We present a case of such interaction that led to ICD communication failure following the activation of an LVAD. In this paper, we describe a practical solution to circumvent the communication interference and review the communication links of ICDs and possible mechanisms of ICD-LVAD interactions.

Advanced heart failure treated with continuous-flow left ventricular assist device.

BACKGROUND: Patients with advanced heart failure have improved survival rates and quality of life when treated with implanted pulsatile-flow left ventricular assist devices as compared with medical therapy. New continuous-flow devices are smaller and may be more durable than the pulsatile-flow devices. METHODS: In this randomized trial, we enrolled patients with advanced heart failure who were ineligible for transplantation, in a 2:1 ratio, to undergo implantation of a continuous-flow device (134 patients) or the currently approved pulsatile-flow device (66 patients). The primary composite end point was, at 2 years, survival free from disabling stroke and reoperation to repair or replace the device. Secondary end points included survival, frequency of adverse events, the quality of life, and functional capacity. RESULTS: Preoperative characteristics were similar in the two treatment groups, with a median age of 64 years (range, 26 to 81), a mean left ventricular ejection fraction of 17%, and nearly 80% of patients receiving intravenous inotropic agents. The primary composite end point was achieved in more patients with continuous-flow devices than with pulsatile-flow devices (62 of 134 [46%] vs. 7 of 66 [11%]; P<0.001; hazard ratio, 0.38; 95% confidence interval, 0.27 to 0.54; P<0.001), and patients with continuous-flow devices had superior actuarial survival rates at 2 years (58% vs. 24%, P=0.008). Adverse events and device replacements were less frequent in patients with the continuous-flow device. The quality of life and functional capacity improved significantly in both groups. CONCLUSIONS: Treatment with a continuous-flow left ventricular assist device in patients with advanced heart failure significantly improved the probability of survival free from stroke and device failure at 2 years as compared with a pulsatile device. Both devices significantly improved the quality of life and functional capacity. (ClinicalTrials.gov number, NCT00121485.)

A hazardous finding of a rare anomalous left main coronary artery in a patient with a secundum atrial septal defect.

A 23-year-old male referred for evaluation of a "choking" sensation with exertion and a murmur. A transthoracic echocardiogram demonstrated right atrial and ventricular dilatation, right ventricular volume overload, and a large secundum atrial septal defect (ASD) with left to right shunt and a calculated pulmonary-to-systemic blood flow ratio (Qp/Qs) estimated at 2.3 to 1. Cardiac catheterization also demonstrated evidence of the ASD with Qp/Qs of 4.6 to 1 with a significant step-up in oxygen saturation at the right atrial level. Additionally, an anomalous left main coronary artery (ALMCA) origin from the anterior right coronary cusp was suspected. Using 64-slice multidetector computed tomography coronary angiography (CCTA) the left main coronary artery was seen to arise from the right coronary cusp then traverse between the pulmonary trunk and the proximal ascending aorta before bifurcating into the left anterior descending and circumflex arteries that followed their normal courses distally. Based on the high risk nature of associated sudden death from an anomalous left main coronary artery (ALMCA) coursing between the aorta and the pulmonary trunk, the patient underwent surgical re-implantation of the ALMCA to the left coronary cusp and repair of the ASD. This case highlights a rare finding of a hazardous ALMCA in a patient with a secundum ASD and the utility of CCTA in evaluating the course of coronary anomalies along with other cardiac pathology.

Endocardial catheter ablation of ventricular tachycardia in patients with ventricular assist devices.

BACKGROUND: The outcomes of patients with ventricular assist devices (VADs) who undergo catheter ablation for ventricular tachycardia (VT) have not been reported. OBJECTIVE: The purpose of this study was to assess the feasibility, safety, and efficacy of endocardial VT ablation in patients with VADs. METHODS: We retrospectively reviewed three cases at our institution where endocardial catheter ablation was performed in patients with VADs and incessant VT. RESULTS: Three patients with underlying cardiomyopathies and VADs underwent VT ablation for incessant VT refractory to multiple antiarrhythmic medications. In each case, VT was either eliminated or significantly ameliorated by catheter ablation. No procedure-related complications occurred. The hemodynamic stability afforded by the VAD played an important role in facilitating ablation in two of the cases. CONCLUSION: Catheter ablation for VT in VAD patients appears to be feasible, safe, and effective based on our initial experience. Several technical issues, such as decreases in ventricular volumes that can limit maneuverability of the ablation catheter and potential entrapment of the mapping catheter in the inflow cannula, need to be considered at the time of ablation.

Stress-induced wall motion abnormalities with low-dose dobutamine infusion indicate the presence of severe disease and vulnerable myocardium.

BACKGROUND: Patients with left ventricular (LV) systolic dysfunction due to coronary artery disease (CAD) may develop stress-induced wall motion abnormalities (SWMA) with low-dose (10 microg/kg/min) dobutamine infusion. The clinical significance of low-dose SWMA is unknown. OBJECTIVE: We investigated the clinical, hemodynamic and angiographic correlates of low-dose SWMA in patients with chronic ischemic LV systolic dysfunction. METHODS: Seventy patients with chronic ischemic LV systolic dysfunction who had dobutamine stress echocardiography were studied. Clinical, hemodynamic, and angiographic parameters at rest and low-dose were compared between 38 patients (mean ejection fraction (EF) of 30 +/- 8%) with low-dose SWMA and 32 patients (EF 30 +/- 11%) without low-dose SWMA. RESULTS: Multivariate analysis showed that the number of coronary territories with severe disease (stenosis > or =70%)(P = 0.001, RR = 6.3) was an independent predictor of low-dose SWMA. An increasing number of collateral vessels protected patients from low-dose SWMA (P = 0.011, RR = 0.25). A higher resting heart rate was a negative predictor of low-dose SWMA (P = 0.015, RR = 0.92) but no other hemodynamic variables were predictors. In the patients with low-dose SMA, regions with low-dose SWMA were more likely to be supplied by vessels with severe disease than regions without low-dose SWMA (92% vs 58%, P < 0.001). CONCLUSION: In patients with ischemic LV systolic dysfunction, the extent of severe disease and a lower numbers of collaterals predict the occurrence of low-dose SWMA. Low-dose SWMA is a highly specific marker for severe disease.

Prognostic importance of wall motion abnormalities in patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator.

Patients with extensive regional wall motion abnormalities are predisposed to development of ventricular tachyarrhythmia. The prognostic effect of this in patients with an implantable cardioverter-defibrillator (ICD) and coronary artery disease (CAD) is not known. Echocardiographic left ventricular systolic indexes, wall motion score index (WMSI), and extent of regional akinesia in 140 patients (65 +/- 10 years old; 92% men) with an ICD and CAD were studied. Arrhythmic events requiring ICD therapy and causing death (n = 41, 29%) were recorded over a mean follow-up of 1.4 +/- 0.8 years. Left ventricular basal fractional shortening, ejection fraction, global WMSI, and extent of akinesia, especially in the inferoposterior regions of a right coronary artery territory, were univariate predictors (all p values <0.05). Global WMSI (hazard ratio 2.18, 95% confidence interval 1.03 to 4.65, p = 0.04) and fractional shortening (hazard ratio 0.93, 95% confidence interval 0.88 to 1.00, p = 0.04) were multivariate predictors. Global WMSI (p = 0.04) and > or =2 right coronary region akinetic segments (p = 0.05) provided incremental risk prediction to left ventricular ejection fraction in a global risk-assessment model (chi-square p = 0.001). Presence of right coronary region akinesia better identified those at increased risk of events (p = 0.02) compared with the presence of left anterior descending region akinesia (p = 0.2), independent of systolic function. In conclusion, global WMSI and left ventricular basal fractional shortening were important additional risk predictors of ICD events in CAD. Global WMSI and right coronary region inferoposterior akinesia provided independent and incremental risk assessment to left ventricular ejection fraction and improved identification of those at increased risk of ICD-related events in patients with ischemic cardiomyopathy.

Comparison of tissue Doppler dynamics to Doppler flow in evaluating left atrial appendage function by transesophageal echocardiography.

Tissue Doppler imaging (TDI) patterns from the left atrial appendage (LAA) were evaluated by transesophageal echocardiography. Reproducible, characteristic triphasic or biphasic tissue velocities similar to Doppler flow of the LAA were obtained. Patient peak TDI velocities correlated well with flow and were measurable in atrial fibrillation. Patients with an embolic cerebrovascular accident and in sinus rhythm had higher tissue TDI velocities from the LAA compared with patients without an event, and the groups had similar flow velocities. Hence, Doppler tissue contraction dynamics determined by TDI may complement flow velocities in evaluating LAA function for risk assessment of thromboembolism.