A case of cardiogenic shock due to ventricular dyssynchrony resolved by atrial pacing.

We present a case of a man with ischemic cardiomyopathy and single chamber implantable cardioverter-defibrillator who developed sinus arrest creating sudden dependence on right ventricular (RV) pacing. He presented with cardiogenic shock secondary to abrupt onset ventricular dyssynchrony from RV pacing, which required emergent stabilization and completely resolved with atrial pacing. Learning objective: To establish a basic understanding of cardiogenic shock management. To reinforce the adverse effects associated with right ventricular pacing.

Severe cardiogenic shock and cardiac arrest due to fulminant cardiac sarcoidosis: a case report.

BACKGROUND: Cardiac sarcoidosis is found to occur in approximately 5% of patients with sarcoidosis. Its presentation can typically range from complete heart block to ventricular arrhythmias. This condition can rarely present with severe heart failure and cardiogenic shock requiring aggressive and timely management strategies. Advanced imaging techniques are usually required to assist with its diagnosis. CASE PRESENTATION: A 70-year-old woman with a history of pulmonary sarcoidosis presented with non-ST elevation myocardial infarction, congestive hepatopathy, and acute renal failure. Left heart catheterization showed evidence of non-obstructive coronary artery disease, and right heart catheterization revealed severely elevated filling pressures and depressed cardiac index. She underwent aggressive diuresis and placement of an intra-aortic balloon pump in addition to initiation of inotropic and vasopressor support. While in the cardiac intensive care unit, she experienced frequent episodes of ventricular tachycardia and went into cardiac arrest requiring cardiopulmonary resuscitation. High clinical suspicion for cardiac sarcoidosis was confirmed by cardiac magnetic resonance imaging findings. After starting immunosuppressive therapy for cardiac sarcoidosis, she demonstrated clinical improvement. CONCLUSION: Patients with cardiac sarcoidosis may remain asymptomatic or present with conduction abnormalities and arrhythmias. They rarely present with severe biventricular heart failure and cardiogenic shock, and in such cases, they require timely initiation of pharmacologic and device therapies, along with implementation of mechanical circulatory support.

Spontaneous Coronary Artery Dissection-Induced Takotsubo Syndrome.

A case of an anxious 59-year-old woman, who presented with chest pressure, nausea, and vomiting, is described. After hours of symptoms that worsened despite medical management, cardiac catheterization was performed. Angiography revealed diffuse, long, tubular disease of multiple coronary vessels. Additionally, left ventriculography was consistent with Takotsubo syndrome. Based on both coronary angiography and left ventriculography, it was determined that this patient had concomitant spontaneous coronary artery dissection and Takotsubo syndrome.

Axillary Artery Hemostasis Post-Intra-Aortic Balloon Pump Failure.

Intra-aortic balloon pump via the axillary approach has been increasingly utilized to facilitate physical rehabilitation prior to definitive heart failure therapy. There is a high risk of device fracture with loss of arterial accessibility. Three cases are presented that demonstrate innovative arteriotomy hemostasis techniques for malfunctioning axillary intra-aortic balloon pumps. (Level of Difficulty: Intermediate.).

Implementation and Impact of Home-Based Cardiac Rehabilitation in a Veterans Affair Medical Center.

INTRODUCTION: In patients with prior myocardial infarction (MI), cardiac rehabilitation (CR) has been shown to reduce all-cause mortality, cardiac mortality, and risk of recurrent MI. Medically supervised cardiac rehab has challenges such as increased patient and center cost, patient transportation issues, patient time commitment, and increased need for resources. Home-based cardiac rehabilitation (HBCR) is an innovative alternative to medically supervised CR which can help to address some of the aforementioned issues. HBCR has been shown to have similar patient outcomes when compared to medically supervised CR; however, implantation efforts and experiences within Veteran Affair (VA) facilities were limited. Thus, we sought to describe our implementation efforts and outcomes of HBCR at our VA medical center, since our VA medical center does not offer an on-site medically supervised CR program. MATERIALS AND METHODS: The project was not reviewed by our institutional review board as this quality improvement project was determined by our VA medical service chief to not qualify as human subjects research. Veterans eligible for CR in our VA medical system were enrolled in a 12-week HBCR program. Veterans performed exercise training at home with equipment provided at no cost. In addition, participating veterans received nutrition counseling, smoking cessation encouragement, stress management, and psychosocial consultation through weekly telephone calls performed by registered nurses. Progress was measured using Life's Simple 7, Duke Activity status index, 6-minute walk test, and Short Form Health Survey (SF-36) before and after HBCR. Medical records were monitored for death, MI, and readmission to the hospital for CHF within the VA medical system for 1 year after the program was complete. SAS and R were used for data input and analysis. RESULTS: Data from 213 veterans were available for analysis and 136 of these veterans completed the HBCR program; the 95 veterans who did not complete the program either declined enrollment, discontinued follow-up with this program, or failed to actively participate and thus were removed from the program. Veterans who completed the 12-week HBCR program reported significant improvement, when compared before and after HBCR program, in Simple 7, Duke Activity status index metabolic equivalent of tasks, 6-minute walk test, SF-36 physical functioning, SF-36 bodily pain, and SF-36 vitality. Overall survival and recurrent MIs were similar between the veterans who completed and the veterans who did not complete the HBCR program in the 1 year follow-up. Hospital admission for heart failure in the 1-year follow-up was lower among veterans who completed the HBCR program when compared to the veterans who did not complete the HBCR program. CONCLUSIONS: HBCR is an effective alternative to facility-based CR. Veterans who completed the program showed improvement in physical capacity and functional status. Compared to those who were eligible but did not complete the program, hospitalization for heart failure was reduced after completing HBCR.