Repeated Syncope Following COVID-19 Infection.

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Pilsicainide Toxicity-Induced Brugada-Like ST Segment Elevation and Increased Pacing Voltage Threshold.

Pilsicainide is a class Ic antiarrhythmic agent that exhibits fully selective sodium channel blockade. In Japan, it is one of the most prescribed medicines for rhythm control in atrial fibrillation. Pilsicainide is mainly excreted by the kidney. Therefore, the plasma concentration of pilsicainide is likely to be increased in patients with renal insufficiency. In this case report, a 90-year-old woman presented with generalized fatigue and loss of appetite. Her ECG showed marked bradycardia and coved-type ST-segment elevation similar to that of the Brugada type 1 pattern. Owing to dehydration, her renal function indices worsened compared with those measured four months prior. The plasma pilsicainide concentration was elevated to 2.67 µg/mL (therapeutic range: 0.20-0.90 µg/mL), indicating pilsicainide toxicity. A transvenous temporary pacemaker was placed; however, the pacing voltage threshold was increased at several sites within the right ventricle. Pilsicainide administration was immediately discontinued. On day 2 of admission, ventricular backup pacing was no longer required, and there was an improvement in renal function and heart failure symptoms, such as pulmonary edema and cardiomegaly. The ECG changes improved alongside the renal function and as the plasma concentration of pilsicainide decreased. In conclusion, elevated plasma concentrations of pilsicainide can induce life-threatening arrhythmias and pacing failure. Therefore, clinicians should prescribe pilsicainide cautiously, particularly in older patients.

Intravascular ultrasound system-guided bail-out stent implantation for iatrogenic aortocoronary dissection: a case report.

Background: Iatrogenic aortocoronary dissection (ACD) is a rare but potentially devastating complication of cardiac catheterization. We describe a case of an iatrogenic ACD following catheter engagement and balloon inflation of the proximal right coronary artery (RCA) during an elective percutaneous coronary intervention (PCI). Case summary: An 81-year-old woman presented with an acute inferior wall ST-elevation myocardial infarction. Emergent coronary angiography revealed the three-vessel diseases. Primary PCI for the culprit lesion of the occluded mid-circumflex artery was successfully performed. After 10 days, an elective PCI for the residual RCA lesions was performed. After the balloon inflation of the proximal RCA, iatrogenic ACD was detected. Intravascular ultrasound-guided stent implantation sealing an entry tear prevented further dissection. The post-operative course was uneventful, and the patient was discharged 1 week later. Follow-up cardiac computed tomography revealed a disappearance of the aortocoronary intramural haematoma. Discussion: This case emphasizes the importance of prompt detection and intervention for iatrogenic ACD. Heart team discussion is essential to determine whether cardiovascular surgery or percutaneous management should be performed. Bail-out stent implantation sealing an entry tear is frequently used and effective, and an intravascular ultrasound system would help to recognize the morphology of ACD, contributing to the safe procedure.

Clinical Characteristics of the Patient With Unmeasurable Ankle-Brachial Index in Endovascular Treatment.

Introduction Ankle-brachial index (ABI) is an important indicator to diagnose lower extremity arterial disease (LEAD). However, patients with unmeasurable ABI are sometimes excluded from the analysis and their clinical characteristics are poorly understood. Methods One hundred twenty-two consecutive Japanese subjects (mean age, 72 years), who underwent successful endovascular treatment (EVT) for lower extremity arteries at our hospital were retrospectively studied. Results Of the 122 patients, 23 (19%) patients presented an unmeasurable ABI before EVT. Five of 23 (22%) had still an unmeasurable ABI one day after EVT. Comorbidities including hypertension, diabetes, dyslipidemia, hemodialysis, smoking, ischemic heart disease, atrial fibrillation, and past-EVT history were not different between ABI measurable and unmeasurable patients. However, patients with unmeasurable ABI presented a significantly higher degree of Rutherford category and a smaller number of tibial vessel runoff than patients with measurable ABI before EVT (p<0.05 and p<0.01, respectively). There was no difference in the lesion site between the two groups. The event rate including all-cause mortality, re-EVT, lower limb amputation, and bypass surgery did not differ between two groups four years after EVT. ABI after four years of initial EVT did not differ between pre-EVT measurable and unmeasurable patients (0.96 vs. 0.84, p=0.48). Conclusions Patients with unmeasurable ABI before EVT were characterized by higher degree of Rutherford categorization and a small number of tibial vessel runoff, but there was no significant difference in outcomes during the follow-up period.

Effect of Constant vs. Variable Moderate-Intensity Load on Peak Oxygen Uptake in Outpatient Cardiac Rehabilitation.

Background: In outpatient center-based cardiac rehabilitation (O-CBCR), moderate-intensity continuous training (MICT) based on the anaerobic threshold (AT) determined by cardiopulmonary exercise stress testing is recommended. However, it is unclear whether differences in exercise intensity within the MICT domain affect peak oxygen uptake (%peakV̇O2). Methods and Results: We retrospectively evaluated patients who underwent O-CBCR at Japan Community Healthcare Organization Osaka Hospital. Those treated with the constant-load method were designated as Group A (n=38), whereas those treated with the variable-load method were designated as Group B (n=48). Although the change in exercise intensity was significantly greater in Group B by approximately 4.5 W, the change in %peakV̇O2 was not significantly different between groups. Group A had a significantly longer exercise time than Group B (by approximately 4-5 min). No deaths or hospitalizations occurred in either group. The percentage of episodes with exercise cessation was similar between the 2 groups, but the percentage of episodes with load reduction was significantly higher in Group B, mostly because of the increased heart rate. Conclusions: In supervised MICT based on AT, the variable-load method increased exercise intensity more than the constant-load method without severe complications, but did not improve %peakV̇O2.

Slow-flow phenomenon after drug-coated balloon angioplasty for lower-extremity arteries is associated with lack of prescribing of calcium channel blockers.

This study aimed to investigate the relationship between prescription drugs and the slow-flow phenomenon after drug-coated balloon angioplasty. Of 30 patients, five (17%) presented with the slow-flow phenomenon. Patients with the slow-flow phenomenon were significantly less commonly prescribed calcium channel blockers than those without the slow-flow phenomenon (P = 0.03). There was no intergroup difference in the prescription of angiotensin II receptor blockers and ß-blockers. The clinical outcomes, including restenosis, thrombosis, target lesion revascularization, and death, did not differ between groups during the 10-month observation period.

Subcutaneous-implantable cardioverter defibrillator lead dislodgement in a juvenile catecholamine-induced polymorphic ventricular tachycardia patient.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a relatively rare inherited arrhythmic disease that causes sudden cardiac death, and is caused by mutations in the cardiac ryanodine receptor (RyR2) or sarcoplasmic reticulum protein calsequestrin 2 gene (CASQ2). A 16-year-old man was diagnosed with CPVT and was implanted with a Subcutaneous-implantable Cardioverter Defibrillator (S-ICD), but defibrillation electrode detachment occurred early after placement. We suspected that a two-incision technique was the possible cause. We also report on changes in surface ECG in remote monitoring of the device. TAKE HOME MESSAGE  Although two-incision techniques are becoming the mainstream method of S-ICD implantation, we should consider that the three-incision technique may be advantageous in highly active patients. Remote monitoring may also be useful for early detection of S-ICD dislodgement.

Septic Shock Due to Urinary Tract Infection in an Immunosuppressed Patient Prescribed Dapagliflozin.

Urinary tract infection (UTI) is one of the adverse effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We describe a rare case of septic shock due to UTI in an immunosuppressed patient prescribed dapagliflozin. A 69-year-old woman was admitted to our hospital for the treatment of pyelonephritis. She was prescribed immunosuppressive drugs for systemic lupus erythematosus and was newly prescribed dapagliflozin for heart failure two weeks prior. One hour after admission, the patient developed hypotension and was diagnosed with septic shock due to UTI. She was administered norepinephrine, hydrocortisone and meropenem. Afterward, she underwent emergent transurethral lithotomy for her right urinary tract stones. The following clinical course was uneventful, and she was discharged on day 17. She had no recurrence of UTI or exacerbation of heart failure without dapagliflozin administration. This case report emphasizes the importance of considering the possibility of UTIs and cases in which SGLT2 inhibitors should be used. If a patient is female and immunocompromised, dapagliflozin should be prescribed more carefully after considering the increased risk of UTIs.

Myocarditis Following the Second Dose of COVID-19 Vaccination in a Japanese Adolescent.

As COVID-19 vaccines continue to be deployed worldwide, countries are now planning to vaccinate their pediatric populations as well. However, several vaccine-related adverse events, including myocarditis, have been reported. Although the incidence of myocarditis after BNT162b2 vaccination is low, it is higher, particularly after receiving the second dose, among young male recipients. A 13-year-old male adolescent presented with chest pain after the second dose of the BNT162b2 vaccination. Electrocardiography, echocardiography, cardiac magnetic resonance imaging, and blood examinations were consistent with myocarditis. He was treated conservatively because his symptoms were relatively mild. In Japan, it is expected that the chances of diagnosing vaccine-related myocarditis will increase as more children are getting vaccinated. Our case report raises concerns to physicians that the COVID-19 vaccination may cause rare cases of myocarditis, which must always be considered as a differential diagnosis.

Multiple Cardiac Calcified Amorphous Tumors.

A 61-year-old woman who underwent hemodialysis presented with heart failure. Echocardiography revealed multiple mobile masses in the left atrium. The masses were excised, and histopathologic examination revealed calcified amorphous tumors. Here, we present several echocardiography images, including 3-dimensional transesophageal echocardiography, demonstrating the revolving masses in the left atrium. (Level of Difficulty: Intermediate.).

Clinical implication of the brachial-ankle pulse wave velocity for endovascular treatment.

This study aimed to evaluate the clinical implication of the brachial-ankle pulse wave velocity (baPWV) for endovascular treatment (EVT). Eighty-four patients who underwent EVT for aortoiliac and femoropopliteal artery were included. In these patients, 36 (43 %) had an ABI improvement above 0.9 a day after EVT. The baPWV in patients who received re-EVT afterwards was significantly higher than that of patients who did not. The area under the receiver operating characteristic curve for the baPWV for predicting re-EVT was 0.788. The optimal cut-off values of the baPWV for re-EVT, specificity, and sensitivity were 2220 cm/s, 93.1 %, and 57.1 %, respectively.

Long COVID presenting with intermittent fever after COVID-19 pneumonia.

A 72-year-old man presented to our hospital with a fever. Chest computed tomography showed typical coronavirus disease 2019 (COVID-19) pneumonia. The fever normalized after a few days, and the pneumonia was alleviated. However, the intermittent fever subsequently re-occurred and persisted for over a month. Various tests, including blood tests, culture tests, and image evaluations, were performed. However, the conclusion was that long COVID was the cause of the intermittent fever as an exclusion diagnosis. Many patients suffer from persistent symptoms of COVID-19, but the symptoms and their durations vary. Here we report a case of prolonged fever after COVID-19 pneumonia.