Pericardial Mesothelioma Presenting as Constrictive Pericarditis.

This case report presents a 60-year-old gentleman with a significant smoking history and possible asbestos exposure who was referred to the emergency department for atrial fibrillation with a rapid ventricular rate and symptoms of heart failure. Labs showed normal brain natriuretic peptide and troponin I. His echocardiography finding suggested constrictive pericarditis with an ejection fraction of 60%. A computed tomography scan was concerning for a pericardial mass. Left and right heart catheterization hinted more toward constrictive physiology; however, some findings were concerning for restrictive physiology. Hence, cardiac magnetic resonance imaging was done, which established the diagnosis of constrictive pericarditis. Pericardiectomy was planned with a maze procedure for atrial fibrillation. However, a malignant neoplasm was seen on a frozen biopsy. Hence, surgery was limited to partial pericardiectomy, as the patient had advanced infiltrative neoplasm that had resulted in constrictive pericarditis. The final pathology report confirmed the diagnosis of malignant pericardial mesothelioma mixed type. Malignancy is usually diagnosed in an advanced stage, like in our case, due to nonspecific initial presentation. A literature review suggests that there is a lack of established consensus on treatment. The response to therapy also seems to be poor and results only in palliation of symptoms, with a median survival of six months from diagnosis despite optimum medical management.

Thirty-Day Readmissions After Percutaneous Left Atrial Appendage Occlusion: Insights from the Nationwide Readmissions Database.

Percutaneous left atrial appendage occlusion (LAAO) provides a nonpharmacological alternative of preventing stroke in patients with non-valvular atrial fibrillation who are poor candidates for oral anticoagulation. Data on 30 day readmission measures following LAAO is limited. Index LAAO procedures and 30 day readmissions were identified using the Nationwide Readmissions Database (NRD) from 2016 to 2018. The rates and causes of 30 day readmissions were studied. Complex samples multivariable logistic regression models were used to identify predictors of 30 day readmission. Among 29,367 patients undergoing LAAO, the rates of 30 day readmissions were 9.2%. The most common overall cause of 30 day readmission was gastrointestinal bleeding (18.5%), followed by heart failure (13.1%), and infection (7.3%). Female gender (OR1.22; 95% CI 1.08-1.38), HF (OR 1.30; 95% CI 1.15-1.47), anemia (OR 1.37; 95% CI 1.11-1.68), chronic lung disease (OR 1.42; 95% CI 1.25-1.62), End stage renal disease (OR 2.75; 95% CI 2.13-3.55), Acute kidney injury (OR 1.66; 95% CI 1.25-2.20), bleeding/transfusion (OR 1.63; 95% CI 1.28-2.09) were found to be independent predictors of 30 days Readmission. The overall rate of 30 day readmission after LAAO was 9.2% with non-cardiac causes (gastrointestinal bleeding) being the most common. Reducing in-hospital complications and identifying optimal post procedural anticoagulation/antithrombotic regimen may help decrease readmissions following LAAO.

Physical Examination for the Detection of Pulmonary Hypertension: A Systematic Review.

We performed a systematic review to determine whether the physical examination can reliably assist in the diagnostic approach for patients suspected of having pulmonary hypertension (PH). Using dual extraction, two investigators independently searched PubMed, Ovid MEDLINE, Cochrane Library, and Embase for studies that compared physical examination findings with a right heart catheterization, from inception until July 10, 2021. We obtained data from four studies that evaluated physical examination findings in patients receiving a right heart catheterization to diagnose PH. Pooled diagnostic odds ratios (DOR) were calculated for right ventricular heave, a loud pulmonic component of the second heart sound (P2), jugular venous pressure (JVP) 3 cm above sternal angle, and a palpable P2. Three physical examination findings had DOR that supports the diagnosis of PH: the JVP > 3 cm above the sternal angle (5.90, 95% CI 2.57, 13.57), a loud P2 (2.91, 95% CI 1.38, 6.10), and a right ventricular heave (2.78, 95% CI 1.12, 6.89). The palpable P2 had a DOR less than one and was not able to be conclusive in diagnosing PH. Our systematic review found a small body of evidence supporting the use of physical examination tests in the diagnostic evaluation of pulmonary hypertension. The JVP > 3 cm above the sternal angle was the most accurate physical examination sign for the diagnosis of PH. Larger cohort studies using a combination of tests may shed more light on the role of the physical examination in the diagnosis and early detection of pulmonary hypertension.

Missed opportunity for anticoagulation in a patient with AL cardiac amyloidosis and rapidly progressive heart failure.

A previously healthy 65-year-old woman presented with progressive symptoms of heart failure. Low-voltage ECG and findings on echocardiography were concerning for infiltrative cardiomyopathy. Cardiac MRI showed biventricular late gadolinium enhancement, and endomyocardial biopsy confirmed monoclonal immunoglobulin light-chain (AL) amyloidosis. Bortezomib-based chemotherapy was initiated, but the patient continued to clinically deteriorate. She required hospital readmission after resuscitated out-of-hospital cardiac arrest attributed to progressive conduction disease, and a permanent pacemaker was implanted. Chest CT angiography showed a small subsegmental pulmonary embolism (PE), but anticoagulation was withheld as her lower extremity Doppler was negative. One month later, another pulseless electrical arrest occurred, due to massive PE. Thereafter, she had refractory class IV congestive heart failure with severe right ventricular dysfunction, and was deemed unsuitable for stem-cell or heart transplantation. This case highlights the predilection for thromboembolism in AL cardiac amyloidosis.

Drug-induced pulmonary arterial hypertension: a review.

Pulmonary arterial hypertension (PAH) is a subgroup of PH patients characterized hemodynamically by the presence of pre-capillary PH, defined by a pulmonary artery wedge pressure (PAWP) ≤15 mmHg and a PVR >3 Wood units (WU) in the absence of other causes of pre-capillary PH. According to the current classification, PAH can be associated with exposure to certain drugs or toxins such as anorectic agents, amphetamines, or selective serotonin reuptake inhibitors. With the improvement in awareness and recognition of the drug-induced PAH, it allowed the identification of additional drugs associated with an increased risk for the development of PAH. The supposed mechanism is an increase in the serotonin levels or activation of serotonin receptors that has been demonstrated to act as a growth factor for the pulmonary artery smooth muscle cells and cause progressive obliteration of the pulmonary vasculature. PAH remains a rare complication of several drugs, suggesting possible individual susceptibility, and further studies are needed to identify patients at risk of drug-induced PAH.

The Prognostic Utility of a Simplified Biventricular Echocardiographic Index of Cardiac Remodeling in Patients with Pulmonary Hypertension.

BACKGROUND: Right ventricular (RV) remodeling has been associated with outcomes in patients with pulmonary hypertension (PH). However, the additive prognostic significance of RV remodeling and left ventricular (LV) morphology in PH is unclear. The objective of this study was to test the hypothesis that the ratio of RV end-diastolic area to LV end-diastolic area is a biventricular index predictive of outcome in patients with PH. METHODS: In total, 139 patients with precapillary PH (mean age, 55 ± 15 years; 75% women) and 22 control subjects (mean age, 40 ± 17 years; 73% women) were studied. The apical four-chamber view was used to measure the RV-to-LV end-diastolic area ratio as an index of biventricular cardiac remodeling. RV free wall and global strain were measured using speckle-tracking echocardiography. The study design was prospective, with all-cause mortality over 5 years predefined as the outcome event. RESULTS: Patients with PH had significantly larger RV to LV end-diastolic area ratios than normal subjects, as expected (1.06 vs 0.67, P < .0001). There were 72 deaths over 5 years. Using a cutoff value of 0.93, patients with RV-to-LV ratios ≥ 0.93 had significantly higher all-cause mortality (hazard ratio,1.84; 95% CI, 1.14-2.96; P = .019). RV global strain was also significantly associated with survival using a cutoff of ≥-15% (hazard ratio, 1.66; 95% CI, 1.03-2.67; P = .044). In a multivariate analysis, only age and biventricular index were independent predictors of survival among other clinical and echocardiographic features. CONCLUSIONS: The RV-to-LV end-diastolic area ratio is a simplified biventricular echocardiographic index of cardiac remodeling that is predictive of long-term survival in patients with PH.