A Systematic Review of the Cardiovascular Manifestations and Outcomes in the Setting of Coronavirus-19 Disease

The impact of coronavirus disease, 2019 (COVID-19), has been profound. Though COVID-19 primarily affects the respiratory system, it has also been associated with a wide range of cardiovascular (CV) manifestations portending extremely poor prognosis. The principal hypothesis for CV involvement is through direct myocardial infection and systemic inflammation. We conducted a systematic review of the current literature to provide a foundation for understanding the CV manifestations and outcomes of COVID-19. PubMed and EMBASE databases were electronically searched from the inception of the databases through April 27th, 2020. A second literature review was conducted to include major trials and guidelines that were published after the initial search but before submission. The inclusion criteria for studies to be eligible were case reports, case series, and observation studies reporting CV outcomes among patients with COVID-19 infection. This review of the current COVID-19 disease and CV outcomes literature revealed a myriad of CV manifestations with potential avenues for treatment and prevention. Future studies are required to understand on a more mechanistic level the effect of COVID-19 on the myocardium and thus provide avenues to improve mortality and morbidity.

The Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing Coronary Revascularization with Percutaneous Ventricular Assist Device Support.

BACKGROUND: Atrial fibrillation (AF) is common in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) requiring percutaneous ventricular assist device (pVAD-Impella®) support during percutaneous coronary interventions (PCI). We evaluated the effects of a coexistent diagnosis of AF on clinical outcomes in patients with AMI-CS undergoing PCI with pVAD support. METHODS: The National Inpatient Sample (2008-2014) was queried to identify patients with AMICS requiring PCI with pVAD support and had a concomitant diagnosis of AF. Propensity-matched cohorts (AF+ vs AF-) were compared for in-hospital outcomes. RESULTS: A total of 840 patients with AMICS requiring PCI with pVAD support (420 AF+ vs 420 AF-) were identified in the matched cohort. Patients with AF were older (mean 69.7±12.0 vs 67.9±11.3 yrs, p=0.030). All-cause in-hospital mortality rates between the two groups were similar (40.5% vs 36.7%, p=0.245); however, higher postprocedural respiratory complications (9.5% vs 4.8%, p=0.007) were seen in AF+ group. In-hospital cardiac arrests were more frequent in the AF- group (32.0% vs 19.2%, p<0.001). We examined the length of stay (LOS), transfer to other facilities, and hospital charges as metrics of health care resource consumption and found that the AF+ cohort experienced fewer routine discharges (13.1% vs 30.2%), more frequent transfers to other facilities including skilled nursing facilities or intermediate care facilities (27.3% vs 17.8%; p<0.001), more frequently required the use of home health care (14.3% vs 7.1%; p<0.001). The mean LOS (11.9±10.1 vs 9.11±6.8, p<0.001) and hospital charges ($308,478 vs $277,982, p=0.008) were higher in the AF+ group. CONCLUSIONS: In patients suffering AMICS requiring PCI and pVAD support, a coexistent diagnosis of AF was not associated with an increase in all-cause in-hospital mortality as compared to patients without AF. However, healthcare resource consumption as assessed by various metrics was consistently greater in the AF+ group.

Effect of right ventricular pacing on left ventricular systolic function in patients with Tetralogy of Fallot.

BACKGROUND: Prevalence of pacemaker-induced cardiomyopathy (PICM) in adults with congenital heart disease is unknown. Tetralogy of Fallot (TOF) is a common diagnosis in the adult congenital heart disease population, and the purpose of this study was to determine association between frequent right ventricular (RV) pacing and temporal decrease in left ventricular ejection fraction (LVEF) from pre-implantation to 2-years post-implantation (LVEFpost-pre) in TOF patients. METHODS: We studied TOF patients that received RV leads only (N = 51) and a reference group of 7 patients with atrial pacing or biventricular pacing. We defined PICM as a ≥10% decrease in LVEF resulting in LVEF <50%. Linear regression was used to assess relationship between frequent RV pacing (≤20%, 21-40%, >40%) and LVEFpost-pre. RESULTS: PICM occurred in 2 (4%) of 51 patients in RV pacing group. LVEFpost-pre was +3% (95% confidence interval [CI] 0% to +5%) in the reference group and -4% (95% CI -11% to +2%) in RV pacing group. No significant difference occured in LVEFpost-pre between the reference group (LVEFpost-pre +3%) vs RV pacing ≤20% (LVEFpost-pre +1%) vs RV pacing 21-40% (LVEFpost-pre -3%) vs RV pacing >40% (LVEFpost-pre -5%), p = 0.318. There was also no association between frequent RV pacing and LVEFpost-pre, R 2 = 0.307, p = 0.10. CONCLUSION: PICM occurred in 4% of TOF patients receiving RV pacing, and there was no association between frequent RV pacing and temporal decline in LVEF. Further studies are required to determine the long-term impact of RV pacing in the TOF population, and explore optimal treatment strategies.

Left Atrial Appendage Morphology as a Determinant for Stroke Risk Assessment in Atrial Fibrillation Patients: Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) is a leading source of emboli that precipitate cerebrovascular accident (CVA) which is correlated with left atrial appendage (LAA) morphology. We aimed to elaborate the relationship between CVA and LAA morphology in AF patients. METHODS: Medline and EMBASE databases were thoroughly searched between 2010-2018 for studies that included atrial fibrillation patients and classified them into two groups based on CVA occurrence. Four different LAA morphologies (Chicken wing CW, Cauliflower, cactus and windsock) were determined in each group by 3D TEE, MDCT or CMRI. New Castle Ottawa Scale was used to appraise the quality of included studies. The risk of CVA before cardiac ablation and/or LAA intervention in CW patients was compared to each type of non-CW morphologies. The extracted data was statistically analyzed in the form of forest plot by measuring the risk ratio (RR) using REVMAN software. P value and I square were used to assess the heterogeneity between studies. RESULTS: PRISMA diagram was illustrated showing 789 imported studies for screening. Three duplicates were removed, and the rest were arbitrated by 2 reviewers yielding 12 included studies with 3486 patients including 1551 with CW, 442 with cauliflower, 732 with cactus 765 with windsock. The risk of CVA in CW patients was reduced by 41% relative to non-CW patients (Total RR=0.59 (0.52-0.68)). Likewise, the risk of CVA in CW patients was less by 46%, 35% and 31% compared to cauliflower (Total RR =0.54(0.46-0.64)), cactus (Total RR =0.65(0.55-0.77)) and windsock (Total RR =0.69(0.58-0.83)) patients respectively. Low levels of heterogeneity were achieved in all comparisons (I square <35% and p value > 0.1). CONCLUSIONS: Patients with non-CW morphologies (cauliflower, cactus and windsock) show a higher incidence of CVA than CW patients. For that reason, LAA appendage morphology could be useful for risk stratification of CVA in AF patients.