Visually estimated coronary artery calcium score improves SPECT-MPI risk stratification.

AIMS: Computed tomographic attenuation correction (CTAC) scans for single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) may reveal coronary artery calcification. The independent prognostic value of a visually estimated coronary artery calcium score (VECACS) from these low-dose, non-gated scans is not established. METHODS & RESULTS: VECACS was evaluated in 4,720 patients undergoing SPECT-MPI with CTAC using a 4-point scale. Major adverse cardiac events (MACE) were defined as all-cause mortality, acute coronary syndrome, or revascularization > 90 days after SPECT-MPI. Independent associations with MACE were determined with multivariable Cox proportional hazards analyses adjusted for age, sex, past medical history, perfusion findings, and left ventricular ejection fraction. During a median follow up of 2.9 years (interquartile range 1.8 - 4.2), 494 (10.5%) patients experienced MACE. Compared to absent VECACS, patients with increased VECACS were more likely to experience MACE (all log-rank p < 0.001), and findings were similar when stratified by normal or abnormal perfusion. Multivariable analysis showed an increased MACE risk associated with VECACS categories of equivocal (adjusted hazard ratio [HR] 2.54, 95% CI 1.45-4.45, p = 0.001), present (adjusted HR 2.44, 95% CI 1.74-3.42, p < 0.001) and extensive (adjusted HR 3.47, 95% CI 2.41-5.00, p < 0.001) compared to absent. Addition of VECACS to the multivariable model improved risk classification (continuous net reclassification index 0.207, 95% CI 0.131 - 0.310). CONCLUSION: VECACS was an independent predictor of MACE in this large SPECT-MPI patient cohort. VECACS from CTAC can be used to improve risk stratification with SPECT-MPI without additional radiation.

Rapid Response to Cytokine Storm Inhibition Using Anakinra in a Patient With COVID-19 Myocarditis.

A 62-year-old woman with coronavirus disease 2019 developed acute respiratory failure and cardiogenic shock in the setting of a systemic hyperinflammatory state and apparent ST-elevation myocardial infarction. Cardiac magnetic resonance imaging showed fulminant acute myocarditis with severe left ventricular dysfunction. Treatment with the recombinant interleukin-1 receptor antagonist anakinra and dexamethasone resulted in rapid clinical improvement, reduction in serum inflammatory markers, and a marked recovery in cardiac magnetic resonance--based markers of inflammation and contractile dysfunction. The patient was subsequently discharged from the hospital. Emerging evidence supports use of anti-inflammatory therapies, including anakinra and dexamethasone, in severe cases of coronavirus disease 2019.

Une femme de 62 ans atteinte de la COVID-19 a développé une insuffisance respiratoire aiguë et un choc cardiogène dans le contexte d'un état hyperinflammatoire général et d'un infarctus du myocarde avec élévation du segment ST apparent. L'imagerie par résonance magnétique cardiaque a révélé une myocardite aiguë fulminante accompagnée d'une dysfonction ventriculaire gauche sévère. Le traitement par l'anakinra, un antagoniste des récepteurs de l'interleukine 1 recombinant, et la dexaméthasone, a entraîné une amélioration clinique rapide, une diminution des marqueurs inflammatoires sériques et un rétablissement marqué selon les marqueurs de l'inflammation et de la dysfonction contractile à la résonance magnétique cardiaque. La patiente a par la suite reçu son congé de l'hôpital. De nouvelles données probantes militent en faveur de l'emploi de traitements anti-inflammatoires, comme l'anakinra et la dexaméthasone, dans les cas sévères de COVID-19.

Intrarenal Doppler Ultrasound Renal Venous Stasis Index Correlates With Acute Cardiorenal Syndrome in Patients With Acute Decompensated Heart Failure.

BACKGROUND: Acute cardiorenal syndrome (ACRS) is associated with adverse outcomes in patients with acute decompensated heart failure (ADHF). Intrarenal venous blood flow can be assessed using Doppler ultrasound and has prognostic significance in ADHF. Although intrarenal Doppler (IRD) may be sensitive to renal congestion, an association between IRD parameters and ACRS has not been demonstrated in an ADHF population. METHODS: Hospitalized patients with ADHF (n = 21) or acute coronary syndrome (ACS; n = 21) were prospectively enrolled. Patients underwent echocardiography, including IRD, using a standard cardiac ultrasound transducer. Intrarenal venous flow was quantified with the renal venous stasis index (RVSI), defined as the duration of absent venous flow time divided by cardiac cycle duration. The primary outcome was acute kidney injury (AKI) as assessed using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. RESULTS: ADHF patients had a similar cardiac index (2.0 ± 0.6 vs 2.1 ± 0.4 L/min per m2, P = 0.91) but higher estimated central venous pressure (13.0 ± 3.2 vs 4.6 ± 2.4 mm Hg, P < 0.001) measured using echocardiography, compared with ACS patients. IRD was abnormal in all ADHF patients and normal in all ACS patients (RVSI 0.62 ± 0.20 vs 0.0 ± 0, P < 0.001). AKI stage II/III occurred in 10 of 21 ADHF patients (48%) vs 0 of 21 ACS patients (P < 0.001), with a mean rise in serum creatinine of 97.7 ± 79.3 vs 16.8 ± 10.9 µmol/L (P < 0.001), respectively. RVSI was correlated with AKI severity in ADHF patients (r = 0.57; P = 0.004). CONCLUSIONS: RVSI is associated with AKI among ADHF patients and may be a useful diagnostic biomarker for ACRS in this setting. Further studies are needed to validate this finding and evaluate the potential efficacy of IRD-guided decongestive therapy in this setting.

INTRODUCTION: Le syndrome cardiorénal aigu (SCRA) est associé à des résultats défavorables chez les patients atteints d'une insuffisance cardiaque en décompensation aiguë (ICDA). Le flux veineux intrarénal qui peut être évalué à l'aide de l'échographie Doppler a une importance pronostique lors d'ICDA. Bien que la Doppler intrarénale (DIR) puisse être sensible à la congestion rénale, l'association entre les paramètres de la DIR et le SCRA n'a pas été démontrée au sein d'une population atteinte d'ICDA. MÉTHODES: Nous avons inscrit de façon prospective les patients hospitalisés atteints d'une ICDA (n = 1) ou d'un syndrome coronarien aigu (SCA; n = 21). Les patients ont subi une échocardiographie, à savoir la DIR, à l'aide d'un transducteur d'échographie cardiaque standard. Le flux veineux intrarénal a été quantifié à l'aide de l'indice de stase veineuse rénale (ISVR), défini par la durée de l'absence du débit veineux divisée par la durée du cycle cardiaque. Le critère d'évaluation principal était l'insuffisance rénale aiguë (IRA) selon les critères de KDIGO (Kidney Disease: Improving Global Outcomes). RÉSULTATS: Les patients atteints d'ICDA avaient un indice cardiaque similaire (2,0 ± 0,6 vs 2,1 ± 0,4 l/min par m2, P = 0,91), mais une estimation plus élevée de la pression veineuse centrale (13,0 ± 3,2 vs 4,6 ± 2,4 mmHg, P < 0,001) selon les mesures obtenues à l'échocardiographie, comparativement aux patients atteints d'un SCA. La DIR était anormale chez les patients atteints d'une ICDA et normale chez les patients atteints d'un SCA (ISVR 0,62 ± 0,20 vs 0,0 ± 0, P < 0,001). L'IRA de stade II/III est apparue chez 10 des 21 patients atteints d'une ICDA (48 %) vs 0 des 21 patients atteints d'un SCA (P < 0,001), selon une augmentation moyenne respective des concentrations sériques de la créatinine de 97,7 ± 79,3 vs 16,8 ± 10,9 µmol/l (P < 0,001). L'ISVR corrélait à la gravité de l'IRA chez les patients atteints d'une ICDA (r = 0,57; P = 0,004). CONCLUSIONS: L'ISVR est associé à l'IRA chez les patients atteints d'une ICDA et peut être un biomarqueur diagnostique utile du SCRA dans ce contexte. Des études plus approfondies sont nécessaires pour valider ces conclusions et évaluer l'efficacité potentielle du traitement de décongestion guidé par DIR dans ce contexte.

Percutaneous Left Ventricular Assist Device in Cardiogenic Shock: A Five-Year Single Canadian Center Initial Experience.

BACKGROUND: Mechanical circulatory support in cardiogenic shock (CS) with percutaneous left ventricular assist devices (PVADs) has expanded rapidly, but there is a paucity of Canadian data. Conflicting observational reports have emerged regarding the benefit of PVADs in CS. We describe a 5-year experience with Impella CP for CS at a single Canadian tertiary care centre. METHODS: Consecutive adult patients with CS supported with Impella CP were included. Comprehensive clinical data and outcomes were retrospectively assessed. We evaluated patient characteristics, patterns of care, in-hospital outcomes, 6-month survival, and predictors of survival. RESULTS: Thirty-four patients were supported with Impella CP for CS over 5 years. A majority had acute myocardial infarction (94%) with advanced CS (68% Society for Cardiovascular Angiography and Intervention [SCAI] stage D or E). Survival to discharge was 58%. In patients who survived to discharge, 6-month survival was 100% with excellent functional status. SCAI CS stage and initial serum lactate showed significant associations with survival. There was also a trend towards improved survival with shorter door-to-PVAD time. Clinically significant bleeding was common (26%), and 3 patients had device-related vascular complications. CONCLUSION: Impella CP may have a role in carefully selected patients with CS. The SCAI shock classification and serum lactate may facilitate patient selection, and minimizing door-to-support time as well as bleeding complications are important considerations. Further clinical investigations, particularly in a Canadian setting, will be necessary to establish the role of this new technology in CS.

CONTEXTE: L'assistance circulatoire mécanique en cas de choc cardiogénique (CC) avec des dispositifs d'assistance ventriculaire gauche percutanée s'est rapidement développée, mais les données canadiennes restent rares. Des rapports d'observation contradictoires ont émergé concernant les avantages des dispositifs d'assistance ventriculaire gauche percutanée en cas de CC. Nous décrivons une expérience de cinq ans avec l'Impella CP pour les CC dans un seul centre de soins tertiaires canadien. MÉTHODES: Des patients adultes assistés par l'Impella CP, consécutivement à un CC, ont été inclus. Les données et les conclusions cliniques détaillées ont été évaluées rétrospectivement. Nous avons évalué les caractéristiques des patients, les modèles de soins, les bilans en milieu hospitalier, la survie à six mois et les indicateurs de survie. RÉSULTATS: Trente-quatre patients ont été pris en charge avec l'Impella CP pour un CC sur une période de cinq ans. Une majorité d'entre eux ont subi un infarctus aigu du myocarde (94 %) avec un CC avancé (68 % au stade D ou E sur l'échelle de la Society for Cardiovascular Angiography and Intervention [SCAI]). La survie jusqu'au congé hospitalier était de 58 %. Chez les patients qui ont survécu jusqu'à leur congé de l'hôpital, la survie à six mois était de 100 % avec un excellent état fonctionnel. Le stade de leur CC selon la SCAI et le lactate sérique initial ont montré des associations significatives avec le taux de survie. On a également constaté une tendance à l'amélioration de la survie avec un temps de porte à dispositifs d'assistance ventriculaire gauche percutanée raccourci. Des hémorragies importantes étaient fréquentes (26 %) et trois patients présentaient des complications vasculaires liées au dispositif. CONCLUSION: L'Impella CP pourrait avoir un rôle chez des patients atteints de CC soigneusement sélectionnés. La classification du choc selon la SCAI et le niveau de lactate sérique peuvent faciliter la sélection des patients, et la réduction du temps de « porte à assistance ¼ ainsi que les complications hémorragiques constituent des considérations d'importance. D'autres investigations cliniques, en particulier dans un contexte canadien, seront nécessaires pour établir le rôle de cette nouvelle technologie dans le CC.

Fulminant Bacterial Myocarditis Presenting as Myocardial Infarction.

A previously healthy man presented with inferior myocardial infarction and recent upper respiratory tract infection. Bacteremia was detected and treated; however, the patient developed refractory polymorphic ventricular tachycardia storm and shock. Clinical autopsy revealed the diagnosis of isolated bacterial myocarditis. (Level of Difficulty: Beginner.).

Monomorphic Ventricular Tachycardia as a Presentation of Giant Cell Myocarditis.

BACKGROUND: Idiopathic giant cell myocarditis (GCM) has a fulminant course and typically presents in middle-aged adults with acute heart failure or ventricular arrhythmia. It is a rare disorder which involves T lymphocyte-mediated myocardial inflammation. Diagnosis is challenging and requires a high index of suspicion since therapy may improve an otherwise uniformly fatal prognosis. CASE SUMMARY: A previously healthy 54-year-old female presented with hemodynamically significant ventricular arrhythmia (VA) and was found to have severe left ventricular dysfunction. Cardiac MRI demonstrated acute myocarditis, and endomyocardial biopsy showed giant cell myocarditis. She was treated with combined immunosuppressive therapy as well as guideline-directed medical therapy. A secondary prevention implantable cardioverter defibrillator (ICD) was implanted. DISCUSSION: GCM is a rare, lethal myocarditis subtype but is potentially treatable. Combined immunosuppression may achieve partial clinical remission in two-thirds of patients. VA is common, and patients should undergo ICD implantation. More research is needed to better understand this complex disease. LEARNING OBJECTIVES: Giant cell myocarditis is an incompletely understood, rare cause of myocarditis. Patients present predominately with heart failure and dysrhythmia. Diagnosis is confirmed by histopathology, and immunosuppression may improve outcomes. ICD implantation should be considered. In the absence of treatment, prognosis is poor with a median survival of three months.

Fulminant Pneumococcal Pericarditis in a Previously Healthy Patient.

Purulent pericarditis is a rare acutely life-threatening condition. Initial symptoms, signs, and investigations can be nonspecific. Echocardiography is invaluable for establishing the diagnosis and initial management. We present a case of a previously healthy patient with purulent pericarditis caused by Streptococcus pneumoniae in the absence of a primary focus of infection. The patient deteriorated rapidly with cardiac tamponade and septic shock and was managed successfully by a combined medical and surgical approach.

Perineural invasion in prostate cancer patients who are potential candidates for active surveillance: validation study.

OBJECTIVE: To validate whether perineural invasion (PNI) on needle biopsy should represent an exclusion criterion in patients considered for active surveillance (AS). Validation was performed in an independent cohort of patients who fulfilled the Epstein AS criteria, but proceeded to surgery, as recent study showed that PNI in this scenario was not associated with adverse findings on radical prostatectomy. METHODS: Biopsy, prostatectomy, and clinical data of 845 patients who met the Epstein AS criteria were retrieved from the institutional prostate cancer database. We compared the clinical, biopsy, and prostatectomy findings in patients with and without PNI. All patients had a 10-core biopsy and a radical prostatectomy performed between July 2000 and June 2010. RESULTS: PNI was present in 63 of 845 (7.4%) patients. Clinical findings were not significantly different between patients with and without PNI. PNI vs no PNI patients demonstrated slightly larger cancer volume on biopsy (2.5% vs 1.8%; P<.001) and greater proportion of 2-core positive biopsies (57.1% vs 36.8%; P=.001). No significant differences were found between the patients with and without PNI regarding the organ-confined disease (95.2% vs 96.4%; P=.5), positive margins (20.6% vs 16.4%; P=.39), tumor volume (8.2% vs 7.3%; P=.36), and prostatectomy Gleason score (≤6 vs >6; P=.13). CONCLUSION: We confirm that finding PNI on biopsy should not influence the decision to exclude patients from AS, if Epstein criteria are met. Although patients with biopsy PNI demonstrated greater volume of cancer and rate of 2-positive cores, PNI on biopsy was not associated with worse prostatectomy findings.