Rivaroxaban Failure Presenting With Renal Infarction in a Patient With Persistent Atrial Fibrillation: A Case Report.

Direct oral anticoagulants (DOAC) are the preferred choice of anticoagulation for patients with atrial fibrillation. DOACs are always preferred over vitamin K antagonists due to their better safety profile in terms of life-threatening bleeding and decreased need for INR (international normalised ratio) monitoring. Although the most commonly used anticoagulation, failure to DOAC has been reported. Here we present a rare case of rivaroxaban failure presenting with left renal infarction in a patient who had dense spontaneous echocardiographic contrast in the left atrium visualised by transthoracic echocardiography.

Development and Validation of a Machine Learning Risk-Prediction Model for 30-Day Readmission for Heart Failure Following Transcatheter Aortic Valve Replacement (TAVR-HF Score).

Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis across the spectrum of surgical risk. About one-third of 30-day readmissions following TAVR are related to heart failure (HF). Hence, we aim to develop an easy-to-use clinical predictive model to identify patients at risk for HF readmission. We used data from the National Readmission Database (2015-2018) utilizing ICD-10 codes to identify TAVR procedures. Readmission was defined as the first unplanned HF readmission within 30-day of discharge. A machine learning framework was used to develop a 30-day TAVR-HF readmission score. The receiver operator characteristic curve was used to evaluate the predictive power of the model. A total of 92,363 cases of TAVR were included in the analysis. Of the included patients, 3299 (3.6%) were readmitted within 30 days of discharge with HF. Individuals who got readmitted, vs those without readmission, had more emergent admissions during index procedure (33.4% vs 19.8%), electrolyte abnormalities (38% vs 16.7%), chronic kidney disease (34.8% vs 21.2%), and atrial fibrillation (60.1% vs 40.7%). Candidate variables were ranked by importance using a parsimony plot. A total of 7 variables were selected based on predictive ability as well as clinical relevance: HF with reduced ejection fraction (25 points), HF preserved EF (20 points), electrolyte abnormalities (17 points), atrial fibrillation (12 points), Charlson comorbidity index (<6 = 0, 6-8 = 9, 9-10 = 13, >10 = 14 points), chronic kidney disease (7 points), and emergent index admission (5 points). On performance evaluation using the testing dataset, an area under the curve of 0.761 (95% CI 0.744-0.778) was achieved. Thirty-day TAVR-HF readmission score is an easy-to-use risk prediction tool. The score can be incorporated into electronic health record systems to identify at-risk individuals for readmissions with HF following TAVR. However, further external validation studies are needed.

Safety and Feasibility of Staged Versus Concomitant Transcatheter Edge-to-Edge Mitral Valve Repair After Transcatheter Aortic Valve Implantation.

The data on the safety and feasibility of performing concomitant or staged transcatheter edge-to-edge repair (TEER) of the mitral valve with transcatheter aortic valve implantation (TAVI) remains limited. The Nationwide Readmission Database was used to identify TEER and TAVI procedures from October 1, 2015 to December 31, 2019, using the International Classification of Diseases, Tenth Revision, Clinical Modification administrative data. A total of 627 weighted cases of TEER and TAVI procedures were included in the analysis. Of those cases, 453 underwent staged TEER after TAVI, whereas 174 had concomitant TAVI and TEER during the same admission. Patients who underwent staged procedures were mostly men (64.8%, p = 0.02) and had a higher median age of 85 years (interquartile range 79 to 88) versus 82 years (interquartile range 72 to 86) in the concomitant procedure group. The adjusted propensity-matched mortality rate was similar for staged versus same-admission procedures (6.1% vs 7.0%, p = 0.79). In-hospital complication rates, including acute kidney injury, vascular complications, need for percutaneous coronary intervention, mechanical support, and pacemaker implantation, were higher for the same-admission TEER and TAVI group than TEER performed as a staged procedure. Nonhome facility discharges and length of hospital stay (15 vs 4 days) were also significantly higher for the concomitant same-admission TEER and TAVI groups. In conclusion, there was no difference in in-hospital mortality rate between patients who underwent concomitant or staged TEER and TAVI procedures, whereas complication rates were significantly higher in the concomitant group.

Coil Embolization of a Left Anterior Descending Coronary Artery-Pulmonary Artery Fistula: A Case Report.

Coronary artery fistulas may be defined as abnormal connections between a coronary artery and either a heart chamber or the pulmonary artery. Although usually asymptomatic, they can become enlarged and rupture in rare instances, requiring prompt intervention. We present a case of a 66-year-old male patient with a left anterior descending-pulmonary artery fistula managed with coil embolization.

Deeply Inverted and Biphasic T-Waves of Wellens' Syndrome: A Characteristic Electrocardiographic Pattern Not To Forget.

Wellens' syndrome refers to specific electrocardiographic (ECG) abnormalities of deeply inverted T-waves in the precordial leads, mainly V1-V3, associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery. Identifying this specific pattern on the electrocardiogram is important as emergent treatment can prevent life-threatening myocardial infarction. We present a case of Wellens' syndrome that had a combination of inverted and biphasic T-waves patterns and where timely identification of the abnormal ECG pattern by the emergency physician and prompt intervention by the cardiology team prevented the development of myocardial infarction and hence permanent damage to the heart.

Acute Kidney Injury in Transcatheter Aortic Valve Replacement.

Introduction Transcatheter aortic valve replacement (TAVR) has been established as a standard of care for patients with severe aortic stenosis. We aim to study the predictors of acute kidney injury (AKI) after TAVR from a contemporary analysis using the National Inpatient Sample (NIS) database. Methods We performed a national analysis using the NIS database to evaluate predictors of acute kidney injury (AKI) after TAVR. Our study period was from 2015 to 2018, and we identified TAVR patients in all procedure fields. Patients aged less than 18 years were excluded from the study. Results We report data of 173,760 TAVR patients, of which 20,045 (11.5%) had AKI and 153,715 (88.4%) did not. There were three principal findings of our study. First, mortality was higher in patients with AKI compared to patients who did not have AKI (8% vs. 0.8%; p<0.01). Second, patients with chronic kidney disease, weight loss, liver disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, metastatic cancer, and peripheral vascular disease had higher adjusted odds of AKI. Third, length of stay and cost of stay were significantly higher in patients who had AKI during the index admission.  Conclusion Patients with AKI had higher in-hospital mortality. We also report that at baseline, chronic kidney disease, weight loss, liver disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, metastatic cancer, and peripheral vascular disease were important predictors of AKI in patients after TAVR. Length of stay and cost of stay were higher with AKI, which result in higher burden on the health care system due to increased resource utilization.

Predictors of Mortality in Patients With Transcatheter Aortic Valve Implantation: A National Inpatient Sample Database Analysis.

Introduction In recent decades, transcatheter aortic valve implantation (TAVI) has become a treatment of choice for aortic stenosis. The purpose of this study was to evaluate predictors of mortality in patients undergoing TAVI. Methods The National Inpatient Sample database from the year 2011 to 2018 was used to identify all patients undergoing TAVI during the study period. Results A total of 215,983 weighted hospitalizations for TAVI were included in the analysis. We report the following three main findings from our contemporary analysis of the NIS: (1) despite TAVI patients having a high comorbidity burden, mortality remains low at 2.2%, (2) in terms of baseline characteristics, end-stage renal disease, liver disease, congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation, and lung cancer remain significant predictors of mortality in patients undergoing TAVI, and (3) length of stay and cost of stay are significantly higher in patients who died during the hospitalization. Conclusion In conclusion, we report that at baseline, end-stage renal disease, liver disease, atrial fibrillation, and lung cancer are significant predictors of mortality in patients undergoing TAVI.

Trends, predictors, and outcomes of major bleeding after transcatheter aortic valve implantation, from national inpatient sample (2011-2018).

INTRODUCTION: Major bleeding remains one of the most frequent complications seen in transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate outcomes, trends, and predictors of major bleeding in patients undergoing TAVI. METHODS: We utilized the National Inpatient Sample (NIS) data from the year 2011 to 2018. Baseline characteristics were compared using a Pearsonχ2 test for categorical variables and Mann-Whitney U-Test for continuous variables. A multivariable logistic regression model was used to evaluate predictors of major bleeding. Propensity Matching was done for adjusted analysis to compare outcomes in TAVI with and without major bleeding. RESULTS: A total of 215,938 weighted hospitalizations for TAVI were included in the analysis. Of the patient undergoing the procedure, 20,102 (9.3%) had major bleeding and 195,836 (90.7%) patients did not have in-hospital bleeding events. Patients in the major bleeding cohort were older and had greater female gender representation. At baseline patients with thrombocytopenia (Odds Ratio [OR], 1.47[confidence interval (CI), 1.36-1.59]), colon cancer (OR, 1.70[CI, 1.27-2.28]), coagulopathy (OR, 1.17[CI, 1.08-1.27]), liver disease (OR, 1.31[CI, 1.21-1.41]), chronic obstructive pulmonary disease (OR, 1.29[CI, 1.25-1.33]), congestive heart failure (OR, 1.12[CI, 1.08-1.16]), and end-stage renal disease (ESRD) (OR, 1.47[CI, 1.38-1.57]) had higher adjusted rates of major bleeding. The percentage of adjusted in-hospital mortality (14.4% vs. 4.2%, P < 0.01) was significantly higher in the major bleeding group Patients with major bleeding had higher median cost of stay ($235,274 vs. $177,920) and length of stay (7 vs 3 days). CONCLUSION: In conclusion, we report that mortality is higher in patients with major bleeding and that baseline comorbidities like ESRD, liver disease, coagulopathy and colonic malignancy are important predictors of this adverse event.

Garbled speech: a rare presentation of metronidazole-induced neurotoxicity.

Neurotoxicity is a rare but significant side effect of metronidazole. We present, here, a case of a 34-year-old man, presenting with garbled speech and word finding difficulty. He was taking metronidazole for the last 3 months for stage 4 decubitus ulcers. MRI of the brain showed abnormal signal intensities in the splenium of the corpus callosum and dentate nuclei of the cerebellum. The diagnosis of metronidazole-induced neurotoxicity was made based on MRI findings. The antibiotic was stopped leading to resolution of abnormal MRI findings. We advocate that metronidazole can be associated with severe neurotoxicity, but its prompt cessation leads to better outcome and prognosis.

Pathological fracture of femoral neck in a middle-aged woman: a rare presentation of primary hydatid cyst disease in humans.

Hydatid disease in humans is caused by Echinococcus granulosus. It most commonly involves the liver and, to a lesser extent, the lungs and spleen; however, it is known to involve other areas, too. Involvement of bone by hydatid cyst is rare. Here, we describe the case of a 37-year-old woman who presented with pain in the left groin and swelling in the left thigh. The radiological imaging showed a fracture of the femoral neck and cysts in the shaft of the femur. Diagnosis of hydatid cyst was confirmed on the basis of histopathology of biopsy specimens. The patient recovered after surgical excision of the cyst. This case illustrates the various sites and presentations of hydatid cyst disease, and the need to investigate for it if cystic bony lesions are encountered especially in endemic regions, as a delay in diagnosis can lead to long-term morbidity and even death.