Simplified echocardiographic assessment of regional left ventricular wall motion pattern in patients with takotsubo and acute coronary syndrome: The randomized blinded Two-chamber Apical Kinesis Observation (TAKO) study.

BACKGROUND: Differentiating Takotsubo cardiomyopathy (TTC) from acute coronary syndrome involving the left anterior descending coronary artery (LAD-ACS) is difficult due to left ventricular apical wall motion abnormality pattern in both and typically requires an invasive coronary angiography (ICA) study for diagnostic confirmation. OBJECTIVES: To identify differences in the regional wall motion abnormality (RWMA) pattern using a comprehensive comparative analysis of the transthoracic echocardiographic (TTE) findings in patients with TTC versus LAD-ACS. METHODS: This was a retrospective, randomized, blinded comparison study including a derivation cohort of 105 patients with TTC (N=52) or LAD-ACS (N=53) with concomitant TTE and ICA identified from our institutional database. A comprehensive echocardiographic wall motion analysis was performed (unblinded) to search for subtle differences in RWMA patterns by marking the exact locations of the end-systolic hinge points (HP) - defined as the intersection between the normal and abnormal regional myocardial thickening - in all apical views. The HP location relative to mitral annulus in each apical view was compared for symmetry and the apical 2-chamber (A2C) view was identified as having the most consistent, quantitative difference between TTC and LAD-ACS. This A2C quantitative model was then prospectively studied in a randomized, blinded, validation cohort of 30 subjects with either TTC or LAD-ACS by eight echocardiographic readers with all levels of clinical experience. RESULTS: In the unblinded derivation cohort, the A2C view showed that the ratio (1.02) and the absolute distance between the anterior HP (3.57 cm) and the inferior HP (3.53 cm) in TTC was significantly different than the ratio (0.761) and the absolute differences between the AHP (4.5 cm) and the IHP (5.93 cm) in LAD-ACS. An AHP: IHP of 0.96 for men and 0.84 for women was able to correctly categorize 84.8% of male and 91.7% of female patients. When applied to the validation cohort, the model showed fairly accurate results with a 74% prediction rate in diagnosing TTC in female patients. CONCLUSION: We propose a relatively simple 2-D TTE diagnostic tool emphasizing subtle differences in the RWMA pattern in the A2C view alone as a semi-quantitative imaging parameter to help differentiate TTC from LAD-ACS.

The many faces of takotsubo syndrome: A review.

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.

Chronic dysphagia as a presenting complaint for primary mediastinal diffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy in adults. It manifests a variable presentation, depending on the tissue in which it arises. Rarely, it can present as dysphagia to solid and liquid foods in primary oesophageal lymphoma with or without B symptoms. We present a case of a 66-year-old man who presented with 3 months of progressive dysphagia with only a mild associated weight loss. This was later found to be caused by DLBCL of the mediastinum causing external compression of the patient's distal oesophagus and gastric cardia. He was treated with one cycle of standard-of-care chemotherapy and subsequently discharged with outpatient follow-up. We emphasise the importance of ruling out life-threatening conditions such as lymphoma in patients who present with dysphagia, as well as the high variability in presentation of DLBCL.

Long-Term Surveillance of Coronary Artery Dissection in an Orthotopic Heart Transplant Recipient.

We describe a case of an orthotopic heart transplant recipient who presented with chest pain related to blunt chest trauma 3 weeks post-transplantation. Electrocardiogram showed anterior ST-segment elevation. Coronary angiography revealed a dissection of the mid-distal left anterior descending artery with preserved antegrade flow. Conservative management of the coronary artery dissection was pursued. While the patient had a favorable long-term clinical outcome, the coronary dissection persisted on 1- and 2-year follow-up coronary angiography.

Severe Bicuspid Aortic Valve Disease in an Adult Cystic Fibrosis Patient.

Bicuspid aortic valve is the most common congenital heart disease. Bicuspid aortic valves are prone to accelerated degenerative changes and aortopathies. These changes often manifest in adulthood as severe aortic stenosis or mixed aortic valve disease. Cystic fibrosis patients are at high risk of adverse surgical outcomes. As survival in cystic fibrosis continues to increase, managing comorbidities including severe aortic stenosis requires consideration. The relatively non-invasive transcatheter aortic valve replacement has been posed as an intervention for high-risk patients with severe symptomatic aortic stenosis. However, traditional randomized trials have excluded patients with bicuspid aortic valves. Herein we present an extremely rare association of severe bicuspid aortic valve stenosis in an adult cystic fibrosis patient. Furthermore, we discuss the clinical course and a multi-disciplinary approach for the management of this rare scenario.

Remdesivir-Induced Marked Sinus Bradycardia in COVID-19.

Remdesivir has been extensively employed during the coronavirus disease 2019 (COVID-19) pandemic as it has proven to be efficacious against the causative SARS-CoV-2. However, there is not much evidence on the cardiovascular adverse effect profile of remdesivir. In addition, limited data support the occurrence of sinus bradycardia associated with remdesivir. Herein we chronicle a clinical encounter of a patient suffering from COVID-19 whose clinical course was complicated by marked sinus bradycardia that began acutely after remdesivir initiation and resolved on cessation of the medication. The patient denied symptoms and completed a 5-day course with a resolution of bradycardia on completion of medication. We suggest that the physicians be cognizant of this rare side effect of remdesivir and suggest a continuation of this medication unless symptomatic bradycardia precludes management.

Double Lung Transplantation Bridged With Direct Central Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation in a Pulmonary Hypertension Patient With Extreme Mediastinal Shift.

Lung transplantation is increasingly being performed for end-stage lung disease in patients with bronchiectasis and pulmonary hypertension. Outcomes of bilateral lung transplantation (BLT) are better in patients with pulmonary hypertension, whereas single lung transplant remains a controversy in bronchiectasis with fear of infections from the residual diseased lung. However, in patients with adhesions and extreme structural changes due to severe disease, BLT may be considered technically challenging. We describe a case of successful management of a patient with bronchiectasis-induced lung disease causing extreme mediastinal shift with a BLT. The patient was successfully bridged to transplant with central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute decompensated pulmonary hypertension while awaiting transplantation.

Immune Thrombocytopenia Following Booster Dose of the Moderna mRNA-1273 Vaccine.

Vaccine-mediated immune thrombocytopenia, although previously reported, is considered exceedingly rare. The probability of the incidence of profound thrombocytopenia following the COVID-19 mRNA-based vaccine has been less elucidated. We present the case of an 81-year-old female patient who became profoundly thrombocytopenic with bleeding manifestations six days after the Moderna mRNA-1273 vaccine administration. Fortunately, she exhibited platelet count recovery after treatment with intravenous immunoglobulins and steroid therapy. Furthermore, we show that the inherent risk of COVID-19 infection leading to thrombocytopenia significantly outweighs the vaccine's risk.

Euglycemic Diabetic Ketoacidosis Due to SGLT2 Inhibitor in a Patient With Gitelman Syndrome: A Therapeutic Dilemma.

Euglycemic diabetic ketoacidosis (DKA) is a rarely reported side effect of sodium-glucose cotransporter-2 inhibitor (SGLT2i) empagliflozin. A 51-year-old female with Gitelman syndrome and type 2 diabetes mellitus (DM) presented with abdominal pain after a recent hospitalization for acute pancreatitis. Her diabetes medications included metformin, pioglitazone, and empagliflozin. Diabetic ketoacidosis was suspected; however, glucose levels were below the cutoff for DKA; therefore, she was diagnosed with euglycemic DKA. Her pancreatitis workup was insignificant. Severe symptomatic hypokalemia despite aggressive repletion limited the management of DKA with insulin infusion therapy. As her ketonemia resolved, she was initiated on subcutaneous insulin with a small but acceptable decrease in potassium. The therapeutic dilemma of managing euglycemic DKA due to SGLT2i in a patient with Gitelman syndrome has not been previously described.

Cerebral paradoxical embolisation in a patient with cystic fibrosis with patent foramen ovale: a comparative review of literature.

A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.

Recurrent acute coronary syndrome in a patient with spontaneous coronary artery dissection and fibromuscular dysplasia.

A 51-year-old woman who presented in June 2010 with acute coronary syndrome (ACS) and anterior wall motion abnormality on the echocardiogram but was found to have an insignificant angiogram. Eight years later she presented again with ACS and evidence of worsening cardiac wall motion affecting a similar territory; however, the angiogram revealing spontaneous coronary artery dissection of the distal left anterior descending artery. Extravascular screening revealed evidence of multifocal fibromuscular dysplasia. We suggest offering vascular screening for fibromuscular dysplasia in young women who present with ACS and normal angiograms, after weighing in risks and benefits.

Community and healthcare system-related factors feeding the phenomenon of evading medical attention for time-dependent emergencies during COVID-19 crisis.

The current COVID-19 crisis has significantly impacted healthcare systems worldwide. There has been a palpable increase in public avoidance of hospitals, which has interfered in timely care of critical cardiovascular conditions. Complications from late presentation of myocardial infarction, which had become a rarity, resurfaced during the pandemic. We present two such encounters that occurred due to delay in seeking medical care following myocardial infarction due to the fear of contracting COVID-19 in the hospital. Moreover, a comprehensive review of literature is performed to illustrate the potential factors delaying and decreasing timely presentations and interventions for time-dependent medical emergencies like ST-segment elevation myocardial infarction (STEMI). We emphasise that clinicians should remain vigilant of encountering rare and catastrophic complications of STEMI during this current era of COVID-19 pandemic.

Rare Presentation of Pulmonary Embolism Amidst Coronavirus Disease 2019 Era: Utility of Multiorgan Ultrasonography.

Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is the underlying cause of a global crisis that the entire world is facing. It is a highly contagious viral infection, which is why social distancing seems to be effective. Its ability to survive on various surfaces and aerosolize necessitates very meticulous precautions, including airborne isolation for severely ill patients requiring mechanical ventilation. However, these patients may need routine diagnostic investigations including chest computed tomography and chest tomography angiogram scans (CT and CTA) to rule out other potential differential diagnoses and guide management. In this case, we focus on the utility of multiorgan ultrasonography (MOU) at the bedside to diagnose and manage pulmonary embolism (PE) in COVID-19 patients.

Acne on the Valve: Two Intriguing Cases of Cutibacterium Acnes Endocarditis.

Cutibacterium acnes is a skin commensal which is most often regarded as a contaminant when detected on blood cultures. In rare instances, it may be the causative pathogen in severe systemic illnesses. Subacute endocarditis, especially of prosthetic valves and devices, is an important grave pathology caused by Cutibacterium acnes. Herein we report two cases of prosthetic valve endocarditis with varied presentations as valve dehiscence with a "rocking" prosthetic valve apparatus in one encounter and as a septic embolic stroke in the second encounter. Although a rare cause of endocarditis, it becomes an especially important entity in patients with prosthetic devices and should be high in the list of differentials.

Nonseminomatous Extragonadal Germ Cell Tumor Presenting As Early Pericardial Tamponade.

Multiple different types of mediastinal masses may be encountered on imaging techniques in symptomatic and asymptomatic patients. The most frequent mediastinal masses in adults are thymoma, lymphoma, thyroid masses, and germ cell tumors. Potential complications of these masses due to localized invasion include hemoptysis, post-obstructive pneumonia, and superior vena cava syndrome. Pericardial tamponade is usually secondary to pericarditis, trauma, infections, radiation, uremia, vascular diseases, and uremia. However, this report presents a case of a young patient who was found to have a large pericardial effusion and early signs of pericardial tamponade, which have not previously been reported as complications of extragonadal germ cell tumors, to the best of our knowledge.

Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support.

This report describes the case of a 64-year-old man who presented with acute coronary syndrome, depressed left ventricular function, and triple vessel disease on angiogram. The patient refused surgery and underwent high-risk percutaneous coronary intervention through the Impella sheath (Abiomed, Danvers, MA). This is one of the first known cases of single-access protected percutaneous coronary intervention, an innovative technique that brings into consideration the importance of dual vascular access via the Impella sheath.

Les auteurs décrivent le cas d'un homme âgé de 64 ans présentant un syndrome coronarien aigu, une fonction ventriculaire gauche réduite et une triple vasculopathie à l'angiogramme. Le patient a refusé une intervention chirurgicale et a plutôt subi une intervention coronarienne percutanée hautement risquée, réalisée au moyen d'une gaine Impella (Abiomed, Danvers, MA). Il s'agit de l'un des premiers cas connus d'intervention coronarienne percutanée protégée à accès unique, une technique novatrice qui met en lumière l'utilité d'un accès vasculaire double grâce à une gaine Impella.

Two Intriguing Cases of Stanford Type A Acute Aortic Dissection.

Stanford type A acute aortic dissection (AAD) is a life-threatening illness that presents with chest pain and hemodynamic instability. Prompt and accurate evaluation and management are critical for survival as it is a cardiac surgical emergency. We aim to highlight the physicians about this potentially fatal condition, by reporting two cases of Stanford type A AAD, with atypical presentations that were initially misdiagnosed.

Left Bundle Branch Pacing in Transthyretin Cardiac Amyloidosis and Alternating Bundle Branch Block.

Progressive conduction system disease affects patients with transthyretin cardiac amyloidosis, often requiring permanent pacing as the His-Purkinje system is affected. We present a case of left bundle branch pacing in a patient with transthyretin cardiac amyloidosis and infra-Hisian conduction disease with a favorable improvement in cardiac function and stable pacing thresholds. (Level of Difficulty: Intermediate.).