Acute Myocardial Infarction Associated With a Mobile Left Ventricular Thrombi.

The majority of acute coronary syndromes are caused by coronary artery thrombotic occlusions secondary to atherosclerotic plaque erosion or rupture. Coronary embolism is an important yet forgotten underlying cause of acute coronary syndrome. We present a case of a young patient who presented with ST elevation myocardial infarction suspected to be secondary to coronary embolization originating from a left ventricular thrombus.

Seckel syndrome presenting with complete heart block.

Seckel syndrome is a rare autosomal recessive disorder characterized by facial dysmorphic features known as bird-headed dwarfism. Only about 100 cases have been reported. Cardiac anomalies have been described as a potential association with Seckel syndrome. We report a 21-year-old woman with Seckel syndrome and epilepsy who presented with status epilepticus. She was hypotensive and bradycardic. Her electrocardiogram showed complete heart block. She was placed on transcutaneous pacer with no response. A transvenous pacemaker was placed before inserting a suitable permanent pacemaker for her size. This is the third case of complete heart block associated with Seckel syndrome and raises concern about the potential association.

Intravenous thrombolysis for the management of acute ischemic stroke in patients therapeutically anticoagulated with heparin: A review.

BACKGROUND: Intravenous thrombolysis (IVT) with alteplase is effective in acute ischemic stroke (AIS). However, its use rate remains low due to the many exclusion criteria. Recent guidelines recommend excluding patients suffering AIS with an elevated aPTT secondary to heparin exposure from receiving IVT. The purpose of this review is to explore the safety and efficacy of IVT in patients therapeutically anticoagulated with heparin. We also propose a treatment algorithm for IVT in patients with AIS that are therapeutically anticoagulated with heparin. METHODS: We performed a systematic review of PubMed and Embase through March 2020 to identify the literature regarding AIS in patients exposed to heparin, followed by IVT treatment, emphasizing safety, efficacy, and clinical outcome using PRISMA guidelines. RESULTS: We included thirteen articles in the final analysis, including three retrospective studies, two observational studies, one randomized trial, five case reports, and two case series. CONCLUSION: There is limited information about the off-label use of IVT in patients with elevated aPTT. Patients with AIS are excluded from IVT if they have recent exposure to heparin. Our review indicates that this population of patients may benefit from IVT as the cases of active bleeding after IVT are few, and functional outcomes are favorable in the long term suggesting that IVT in therapeutically anticoagulated patients may be safe and efficacious.

B-Type Natriuretic Peptide: A Predictor for Mortality, Intensive Care Unit Length of Stay, and Hospital Length of Stay in Patients With Resolving Sepsis.

BACKGROUND: B-type natriuretic peptide (BNP) is a hormone secreted by cardiomyocytes in response to myocardial ischemia, increased ventricular wall tension, and overload. BNP is utilized as a diagnostic and prognostic marker in congested heart failure (CHF). Its prognostic value in sepsis is unknown. The aim of this study is to determine if BNP correlates with increased in-hospital mortality for septic patients. METHODS: This was a retrospective study of 505 patients admitted for sepsis or severe sepsis or septic shock during the period of January 2013 and August 2014. Patients that received > 3 L of intravenous fluids on presentation were included. Intensive care unit length of stay (ICULOS), hospital length of stay (HLOS) and in-hospital mortality were measured. Mean BNP level was calculated and compared to ICULOS and HLOS and in-hospital mortality. Controlled variables included ejection fraction (measured by echocardiogram within 6 months of presentation), glomerular filtration rate (calculated by Cockroft-Gault equation), patient demographics, and lactic acid trends. Exclusion criteria were no echocardiogram within 6 months of admission, no BNP levels on admission, and no repeat lactate or rising lactate levels within 24 h to indicate worsening sepsis. RESULTS: Patients' mean BNP with in-hospital mortality was 908 pg/mL as compared to mean BNP of 678 pg/mL in survivors. T-test comparisons were statistically significant (P = 0.0375). The Kaplan-Meier curve for BNP as a predictor for in-hospital mortality showed that for the first 25 days, patients with BNP higher than 500 pg/mL had a higher mortality than patients with BNP lower than 500 pg/mL. When comparing HLOS, there is a statistically significant correlation (P = 0.0046). A similar scatter plot was prepared for ICULOS which showed there was a weak positive correlation (r = 0.199). CONCLUSION: Septic patients with in-hospital mortality had an average BNP of 908 pg/mL and statistically significant higher HLOS.

Reduced Right Ventricular Function Predicts Long-Term Cardiac Re-Hospitalization after Cardiac Surgery.

BACKGROUND: The significance of right ventricular ejection fraction (RVEF), independent of left ventricular ejection fraction (LVEF), following isolated coronary artery bypass grafting (CABG) and valve procedures remains unknown. The aim of this study is to examine the significance of abnormal RVEF by cardiac magnetic resonance (CMR), independent of LVEF in predicting outcomes of patients undergoing isolated CABG and valve surgery. METHODS: From 2007 to 2009, 109 consecutive patients (mean age, 66 years; 38% female) were referred for pre-operative CMR. Abnormal RVEF and LVEF were considered <35% and <45%, respectively. Elective primary procedures include CABG (56%) and valve (44%). Thirty-day outcomes were perioperative complications, length of stay, cardiac re-hospitalizations and early mortaility; long-term (> 30 days) outcomes included, cardiac re-hospitalization, worsening congestive heart failure and mortality. Mean clinical follow up was 14 months. FINDINGS: Forty-eight patients had reduced RVEF (mean 25%) and 61 patients had normal RVEF (mean 50%) (p<0.001). Fifty-four patients had reduced LVEF (mean 30%) and 55 patients had normal LVEF (mean 59%) (p<0.001). Patients with reduced RVEF had a higher incidence of long-term cardiac re-hospitalization vs. patients with normal RVEF (31% vs.13%, p<0.05). Abnormal RVEF was a predictor for long-term cardiac re-hospitalization (HR 3.01 [CI 1.5-7.9], p<0.03). Reduced LVEF did not influence long-term cardiac re-hospitalization. CONCLUSION: Abnormal RVEF is a stronger predictor for long-term cardiac re-hospitalization than abnormal LVEF in patients undergoing isolated CABG and valve procedures.