COVID-19 and Cardiomyopathy in African Americans: An Early Single-Center Experience.

Introduction The 2019 coronavirus pandemic has taken a toll on our society. Although most patients report minimal symptoms, a small proportion of patients have reported significant respiratory symptoms that led to admission to the inpatient medical ward or even the intensive care unit. Complications and long-term sequela of COVID-19 are still being reported and studied. The presence of cardiomyopathy, whether established or new-onset and its effect on inpatient mortality, admission to the intensive care unit or length of stay hasn't been studied.  Methods All inpatient hospitalizations in our database between March 1, 2020, and April 30, 2020, due to COVID-19 were reviewed. Patients who had at least a limited echocardiogram during this time were included in the study if they were above the age of 18. Patients were then assigned to three groups. The first group had patients with normal left ventricular systolic function. The second group had established cardiomyopathy that persisted throughout admission. The third group had patients who were found to have new-onset cardiomyopathy during admission.  Results The inpatient mortality, although high and variable, wasn't significantly different between the three groups. Also, there was no significant difference between admission to the intensive care unit, disposition at discharge, or oxygenation status at 24 hours between the three groups. The length of stay in the established cardiomyopathy group was markedly lower, and we suspect that could be due to more aggressive discussions about end-of-life care.  Conclusion Early COVID-19 experience at our center revealed a relatively high mortality rate that was primarily due to respiratory failure. The presence of established or new cardiomyopathy didn't appear to alter the outcomes significantly early in the pandemic.

Isolated Sub-Pulmonic Valve Endocarditis in a Patient With a History of Konno Procedure and Mechanical Aortic Valve.

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Isolated Ventricular Septal Aneurysm: A Differential Diagnosis for a Right Sinus of Valsalva Aneurysm.

BACKGROUND A ventricular septal aneurysm (VSA) is rare and almost always an incidental finding on cardiac imaging. It is rarely an isolated phenomenon and is more commonly associated with other forms of congenital heart disease such a ventricular septal defect (VSD). Differentiating a ventricular septal aneurysm from an aneurysm of the right sinus of Valsalva is crucial as the latter usually has a more aggressive course and may require surgical intervention. Cardiac computed tomography (cardiac CT) or cardiac magnetic resonance imaging (CMR) may help confirm the diagnosis. CASE REPORT We report a case of a 42-year-old obese Japanese man with a past medical history of hyperlipidemia who described occasional effort-related palpitations when climbing stairs over the past few months but no anginal symptoms. Echocardiogram revealed normal left ventricular systolic with a presumed right sinus of Valsalva aneurysm measuring around 1.5 cm. A coronary CTA was obtained to further delineate the aneurysm and revealed normal CT angiographic appearance of a right dominant coronary artery circulation with a small aneurysmal outpouching of the membranous ventricular septum measuring 13×17 mm without any evidence of shunting, along with focal calcification of the medial aspect of the tricuspid annulus. The right sinus of Valsalva appeared normal on coronary CTA. CONCLUSIONS Membranous ventricular septal aneurysm is a rare condition that is almost always an incidental finding on echocardiography and can be mistaken for an aneurysm of the right sinus of Valsalva. Multimodality imaging and high degree of clinical suspicion are needed to accurately diagnose a ventricular septal aneurysm and to achieve favorable outcomes. A VSA usually has a benign course and is rarely a cause of arrythmia, right ventricular outflow obstruction, or valvular insufficiency.

Arteriolar vs. valvular thrombosis: Pick your evil!

BACKGROUND: Anticoagulation therapy for mechanical prosthetic valves is limited to vitamin K antagonists, unfractionated heparin and low-molecular-weight-heparin. Other forms of anticoagulation are either contraindicated or have not been well studied. Hence, anticoagulation for preexisting mechanical valves is controversial if vitamin K antagonists are contraindicated. We present a case involving an end-stage-renal disease patient with both mitral and aortic mechanical valves who developed warfarin-induced calciphylaxis. CASE PRESENTATION: A 72-year-old male with history of end-stage renal disease, chronic atrial fibrillation and rheumatic heart disease status post mitral and aortic valve replacements presented with complaints of left thigh erythema with skin induration. Despite multiple antibiotic regimens for presumed cellulitis, the skin lesions progressed to necrotic ulcers. A biopsy revealed evidence of calciphylaxis; a lethal condition typically associated with renal disease. The patient was on warfarin for anticoagulation of his mechanical heart valves as well as prophylactically for atrial fibrillation. Warfarin contributes to the development of calciphylaxis and needed to be exchanged to avoid progression of the ulceration. The only other acceptable option for long-term anticoagulation was subcutaneous unfractionated heparin but this approach was not taken. The patient suffered from further sequelae of calciphylaxis and eventually expired. CONCLUSION: Calciphylaxis is a rare, serious disorder that presents with skin ischemia and necrosis mainly in end-stage renal disease patients. The pathogenesis and treatment are poorly understood and the prognosis remains grave. It is proposed that certain medications, including warfarin, contribute to its evolution. The optimal anticoagulation therapy in those with concomitant warfarin-induced calciphylaxis and mechanical valves is undetermined. Further studies are essential to establish new anticoagulation regimens in these devastating circumstances.

Cardiac sarcoidosis presenting as constrictive pericarditis.

In patients with cardiac sarcoidosis, the sarcoid granulomas usually involve the myocardium or endocardium. The disease typically presents as heart failure with ventricular arrhythmias, conduction disturbances, or both. Constrictive pericarditis has rarely been described in patients with sarcoidosis: we found only 2 reports of this association. We report the case of a 57-year-old man who presented with clinical and hemodynamic features of constrictive pericarditis, of unclear cause. He was admitted for treatment of recurrent pleural effusion. After a complicated hospital course, he underwent pericardiectomy. His clinical and hemodynamic conditions improved substantially, and he was discharged from the hospital in good condition. The pathologic findings, the patient's clinical course, and his response to pericardiectomy led to our diagnosis of cardiac sarcoidosis presenting as constrictive pericarditis. In addition to the patient's case, we discuss the nature and diagnostic challenges of cardiac sarcoidosis. Increased awareness of this disease is necessary for its early detection, appropriate management, and potential cure.

Long-term follow-up of lesion-specific outcomes comparing drug-eluting stents and bare metal stents in diseased saphenous vein grafts.

Saphenous vein grafts (SVGs) are a common choice for bypassing obstructed coronary arteries. Repeat coronary artery bypass grafting has been found to have substantial rates of morbidity and mortality; therefore, SVG percutaneous intervention has emerged as a positive alternative for revascularization. Stenting of SVGs has been shown to be more beneficial than medical management or balloon angioplasty alone. The literature is conflicting with regard to which type of stent-bare metal stent (BMS) or drug-eluting stent (DES)-is best suited for treating graft failure. The authors provide long-term follow-up data of lesion-specific outcomes when comparing DES versus BMS in SVGs.

A forgotten devil; Rupture of mitral valve papillary muscle.

BACKGROUND: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. CASES REPORT: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. CONCLUSIONS: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.

Impact of a continuous quality improvement initiative on appropriate use of coronary computed tomography angiography. Results from a multicenter, statewide registry, the Advanced Cardiovascular Imaging Consortium.

OBJECTIVES: The purpose of the study was to determine the effectiveness of a collaborative educational, continuous quality improvement (CQI) initiative to increase appropriate use of coronary computed tomography angiography (CCTA). BACKGROUND: Potential overuse of CCTA has prompted multisociety appropriate use criteria (AUC) publications. METHODS: This prospective, observational study was conducted with pre-intervention (July 2007 to June 2008), intervention (July 2008 to June 2010), and follow-up (July 2010 to December 2010) periods during which patients were enrolled in the Advanced Cardiovascular Imaging Consortium (ACIC) at 47 Michigan hospitals. Continuous education was provided to referring physicians. The possibility of losing third-party payer coverage in the absence of a measurable change in AUC was emphasized. AUC was compared between the 3 periods. RESULTS: The study group included 25,387 patients. Compared with the pre-intervention period, there was a 23.4% increase in appropriate (61.3% to 80%, p < 0.0001), 60.3% decrease in inappropriate (14.6% to 5.8%, p < 0.0001), 40.8% decrease in uncertain (10.3% to 6.1%, p < 0.0001), and 41.7% decrease in unclassifiable (13.9% to 8.1%, p < 0.0001) scans during follow-up. Between pre-intervention and follow-up, change in CCTA referrals by provider specialty were cardiology (appropriate: 60.4% to 79.5%; inappropriate: 13% to 5.2%; p < 0.0001), internal medicine/family practice (appropriate: 51.1% to 70.4%; inappropriate: 20.2% to 12.5%; p < 0.0001), emergency medicine (appropriate: 83.6% to 91.6%; inappropriate: 9.1% to 0.6%; p < 0.0001), and other (appropriate: 61.1% to 83.2%; inappropriate: 18.6% to 5.9%; p < 0.0001). CONCLUSIONS: Application of a systematic CQI and emphasis on possible loss of coverage were associated with a significant improvement in the proportion of CCTA examinations meeting AUC across referring physician specialties.

Rationale, design, and goals of the Advanced Cardiovascular Imaging Consortium (ACIC): A Blue Cross Blue Shield of Michigan collaborative quality improvement project.

BACKGROUND: Coronary computed tomography angiography (CCTA) is an emerging noninvasive anatomical method for evaluation of patients with suspected coronary artery disease (CAD). Multicenter clinical registries are key to efforts to establish the role of CCTA in CAD diagnosis and management. The Advanced Cardiovascular Imaging Consortium (ACIC) is a statewide, multicenter collaborative quality initiative with the intent to establish quality and appropriate use of CCTA in Michigan. METHODS: The ACIC is sponsored by the Blue Cross Blue Shield of Michigan/Blue Care Network, and its 47 sites include imaging centers that offer CCTA and meet established structure and process standards for participation. Patients enrolled include those with suspected ischemia with or without known CAD, and individuals across the entire spectrum of CAD risk. Patient demographics, history, CCTA scan-related data and findings, and 90-day follow-up data are entered prospectively into a centralized database with strict validation tools and processes. Collaborative quality initiatives include radiation dose reduction and appropriate CCTA use by education and feedback to participating sites and referring physicians. CONCLUSIONS: Across a wide range of institutions, the ACIC permits evaluation of "real-world" utilization and effectiveness of CCTA and examines an alternative, nontraditional approach to utilization management wherein physicians and payers collaborate to address the growing problem of cardiac imaging overutilization.

Effectiveness of implantable cardioverter-defibrillators for the primary prevention of sudden cardiac death in women with advanced heart failure: a meta-analysis of randomized controlled trials.

BACKGROUND: Numerous clinical trials have established a role for implantable cardioverter-defibrillators in the prevention of sudden cardiac death in patients with heart failure. However, questions remain that regard the clinical benefit of these therapies in different patient subgroups. Specifically, the role of implantable cardioverter-defibrillators in women with heart failure for the primary prevention of sudden cardiac death has not been well established. Our objective is to determine whether implantable cardioverter-defibrillators reduce mortality in women with advanced heart failure. METHODS: We searched MEDLINE (1950-2008), EMBASE (1988-2008, week 24), the Cochrane Controlled Trials Register (third quarter, 2008), the National Institute of Health ClinicalTrials.gov database, the Food and Drug Administration Web site, and various reports presented at scientific meetings (1994-2007). Eligible studies were randomized controlled trials of implantable cardioverter/defibrillators for the primary prevention of sudden cardiac death in patients with heart failure that reported all-cause mortality as an outcome for the female population. Of the 2619 reports identified, 5 trials that enroll 934 women were included in the meta-analysis. RESULTS: Pooled data from the 5 trials revealed no statistically significant decrease in all-cause mortality in women with heart failure who receive implantable cardioverter-defibrillators (hazard ratio, 1.01; 95% confidence interval, 0.76-1.33). CONCLUSIONS: Implantable cardioverter-defibrillator therapy for the primary prevention of sudden cardiac death in women does not reduce all-cause mortality. Further studies are needed to investigate the reasons for this ob servation and to define the population of women who may benefit most from implantable cardioverter-defibrillator therapy.

Suspected Legionella-induced perimyocarditis in an adult in the absence of pneumonia: a rare clinical entity.

Legionella infection can manifest itself in many clinical forms, most commonly as pneumonia, but rarely in the form of myocardial involvement. Legionella with myocardial involvement independent of pneumonia is almost never seen in the adult population and therefore is cited only a handful of times in the medical literature. When reported, Legionella carditis itself typically occurs as an isolated pericarditis with effusion. Cases of isolated Legionella with myocardial involvement, but without associated pneumonia, have been reported among children. To our knowledge, there are no reported cases of Legionella myocarditis and pericarditis presenting concurrently with or without pneumonia, in either an adult or a pediatric population. Herein, we report a rare manifestation of Legionella pneumophila-induced perimyocarditis (strongly suspected, if not incontrovertibly proved) in an adult, in the absence of pneumonia.

Incidental finding of a large pulmonary valve fibroelastoma: a case report.

Papillary fibroelastoma (PFE) is an uncommon primary neoplasm of cardiac origin. They are solitary neoplasms that historically were an incidental finding at the time of autopsy. With the advent of two-dimensional echocardiography, symptomatic cases have been reported in current literature, thus causing a paradigm shift in the management of these tumors. Although the majority of PFE are benign, because of their potential risk for complication related to embolic and obstructive phenomena, they are now considered hazardous and require tumor excision even in asymptomatic patients. We report a case of an asymptomatic incidental large papillary fibroelastoma within the right ventricular outflow tract.

Superior vena cava (SVC) thrombosis: diagnosis and follow up by transesophageal echocardiography (TEE).

Hemodialysis catheters (HC) were developed as a vascular access, intended to be a bridging device until a permanent access is placed. Although many reports exist of indwelling catheter-related thrombosis, optimal diagnostic study and therapeutic options are yet to be established. We are presenting a case with HC thrombosis diagnosed by TEE managed conservatively with excellent long-term outcome.