Recovery From COVID-19 Pneumonia in a Heart Transplant Recipient: A Case Report.

Solid-organ transplant patients have a high risk of severe infection related to acute respiratory syndrome coronavirus-2 (SARS-Cov-2). This case represents a 54-year-old woman known as a diabetic, hypothyroidism, and a recent heart transplant recipient who presented with a 1-week history of cough and fatigue. She was hypoxic on presentation to the hospital and progressively declined and required invasive mechanical ventilation. She had respiratory distress and hypoxia and chest x-ray showed progressive bilateral chest infiltrates. She had leukopenia of 3.5 cells *109/L and lymphopenia of 0.2 cells *109/L. The inflammatory markers were increased: C-reactive protein, 25 mg/L; ferritin, 1106 ng/mL; lactate dehydrogenase, 632 U/L; and interleukin-6, 87 pg/mL. She was treated for severe coronavirus disease 2019 (COVID-19) pneumonia. Her treatment involved supportive care with mechanical ventilation, convalescent plasma transfusion, antiviral therapy with favipiravir, intravenous dexamethasone, and reduction of immune suppression medication. This case had a successful recovery through multidisciplinary team management. Solid-organ transplant recipients are a high-risk population who need an individualized care plan for the optimization of immunosuppressive medication and treatment of the COVID-19 infection.

Rivaroxaban versus warfarin for the management of left ventricle thrombus.

BACKGROUND: Rivaroxaban has been recently introduced for the management of non-valvular intra-cardiac thrombosis with variable results. We aimed to compare the results of the off-label use of rivaroxaban versus warfarin in the management of patients with left ventricle (LV) thrombus. This research is a retrospective study conducted on 63 patients who had LV thrombus from January to December 2016. We compared patients treated with warfarin (n=35) to patients who had rivaroxaban (n=28), and study outcomes were time to thrombus resolution, bleeding, stroke, and mortality. RESULTS: The median duration of treatment was 9.5 (25th-75th percentiles: 6-32.5) months for rivaroxaban and 14 (3-41) months for warfarin. Thrombus resolution occurred in 24 patients in the warfarin group (68.6%) and 20 patients in the rivaroxaban group (71.4%). The median time to resolution in the warfarin group was 9 (4-20) months and 3 (2-11.5) months in the rivaroxaban group. Thrombus resolution was significantly faster in patients on rivaroxaban (p= 0.019). Predictors of thrombus resolution were thrombus surface area (HR: 1.21; CI 95% (1.0-1.46); p= .048) and the use of rivaroxaban (HR: 1.92; CI 95% (1.01-3.65); p= 0.048). There was no difference in stroke, bleeding, and mortality between both groups. CONCLUSION: Rivaroxaban was as effective and safe as warfarin in managing patients with left ventricle thrombus. Larger randomized clinical trials are recommended to confirm our findings.

Successful treatment of infective endocarditis due to pandrug-resistant Klebsiella pneumoniae with ceftazidime-avibactam and aztreonam.

Pandrug-resistant (PDR) K. pneumoniae refractory to conventional treatment has been reported worldwide, causing a huge burden on the healthcare system, patient safety and the economy. K. pneumoniae is a prominent opportunistic pathogen causing hospital-acquired and community-acquired infections, but is rarely associated with infective endocarditis. Currently, there are sparse data guiding the optimal regimen when commonly used antibiotics fail, notably for the treatment of endocarditis infections. Here we report our experience in treating a 40-year-old female with PDR K. pneumoniae infection of cardiovascular implantable electronic device (CIED) and right-sided infective endocarditis. Initial susceptibility testing of the incriminated pathogen showed an apparent susceptibility to colistin but the prolonged course of colistin, gentamicin and meropenem did not resolve the infection. However, the synergistic combinations of aztreonam with ceftazidime-avibactam was able to overcome resistance and clear the infection rapidly. Genome sequencing showed that the PDR K. pneumoniae isolate belongs to the international high-risk clone ST14. The isolate harbored genes encoding NDM-1, OXA-48, CTX-M-14b, SHV-28 and OXA-1, explaining resistance to all ß-lactams, including carbapenems. It carried the armA gene conferring resistance to all clinically important aminoglycosides and had alterations in GyrA, ParC and MgrB, explaining resistance to ciprofloxacin and colistin.

Tricuspid Valve Regurgitation After Heart Transplantation: A Single-Center 10-year Experience.

BACKGROUND: Tricuspid valve regurgitation may affect the outcomes after heart transplantation. There is a paucity of data reporting the outcomes of heart transplants in our region. The objectives of this study were to report the occurrence of tricuspid regurgitation after heart transplantation, its course, and its effect on survival. METHODS: From 2009 to 2019, 30 patients had heart transplantation at our cardiac center. Their age was 36.73 ± 13.5 years, and 25 (83.33%) were males. Indications for transplantation were dilated cardiomyopathy (n = 21; 72.41%), ischemic cardiomyopathy (n = 8; 26.67%) and hypertrophic cardiomyopathy (n = 1; 3.45%). Cardiopulmonary bypass time was 157.24 ± 34.6 min, and ischemic time was 138 ± 73.56 min. All patients had orthotopic heart transplantation with a bi-caval technique. RESULTS: Eleven patients had severe tricuspid regurgitation postoperatively (37%). The degree of tricuspid regurgitation decreased significantly after 6 months (p = 0.011) and remained stationary during the follow-up. Pre-transplant dilated cardiomyopathy was significantly associated with severe tricuspid regurgitation post-transplant (p = 0.017). The mean follow-up was 39.43 ± 50.57 months. Survival at 10 years was 90% in patients with less than moderate tricuspid regurgitation postoperatively compared to 43% for patients with moderate and severe tricuspid regurgitation (log-rank p = 0.0498). CONCLUSION: Tricuspid regurgitation is a common problem after heart transplantation. Despite the improvement of the degree of tricuspid regurgitation after 6 months, survival was negatively affected by postoperative moderate or severe tricuspid regurgitation. Patients with dilated cardiomyopathy may benefit from concomitant tricuspid valve repair at the time of heart transplantation. Further larger studies are warranted.

Assessment of the quality of anticoagulation management with warfarin in a tertiary care center.

OBJECTIVES: To evaluate the quality of an anticoagulation clinic in a tertiary hospital and identified factors affecting the time in the therapeutic range (TTR) and its relation to different complications. Methods: This single-center retrospective study conducted between March 2015 and June 2016 included 1914 patients receiving warfarin therapy. They were divided into 4 warfarin indication groups: non-valvular atrial fibrillation (AF) (n=403), valvular AF (n=227), prosthetic valves (n=700), and venous or pulmonary embolism (n=584). RESULTS: The median age was 56 (25th, 75th percentiles: [45, 67]) years, and 53.2% were female. The median TTR was 0.52 (0.28, 0.76). Low hemoglobin (0.007) and high alkaline phosphatase (0.020) levels negatively affected the TTR. Venous thromboembolism (VTE) was associated with low TTRs. Minor bleeding occurred in 64 (3.35%), gastrointestinal bleeding in 14 (0.7%), and stroke in 41 (2.2%) patients, with no inter-group differences. The TTR was not associated with minor bleeding (odds ratio [OR]=0.49; p=0.09), gastrointestinal bleeding (OR=0.29; p=0.18), or stroke (OR=1.15; p=0.79). CONCLUSION: Reflecting the real-life experience of anticoagulation control, our patients spend less than half the TTR within the INR. The low target TTR mandates the need to improve service quality and control factors affecting the TTR, including hemoglobin levels and regular visits for patients with VTE.

Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa.

Clinical guidelines for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) are available from several international cardiology associations. Patients with NVAF in the Middle East and North Africa (MENA) region present unique challenges and opportunities related to differences in geography, practice patterns, and patient demographics that are as yet unaddressed in practice guidelines. This review aims to offer a practical perspective on the management of NVAF in patients in MENA and draws on evidence-based guidelines as well as real-world evidence and expert opinion. The literature was searched for relevant original research articles, systematic reviews, meta-analyses, and guideline recommendations addressing the prevention of stroke in patients with NVAF with a focus on issues relevant to the MENA region. Guideline recommendations, best practices, and expert opinion were discussed and agreed on by a working group consisting of cardiologists from across the MENA region. The incidence of stroke secondary to atrial fibrillation in patients across the MENA region is higher than rates reported globally, and this might be attributed to a higher incidence of vascular risk factors and underuse of anticoagulants in patients in the MENA. The available evidence supports the established role of non-vitamin K antagonist oral anticoagulants (NOACs) in the prevention of stroke in patients with NVAF. There is a consistent body of clinical trial and real-world evidence supporting their efficacy for stroke prevention in NVAF, with more favorable bleeding risk profiles relative to vitamin K antagonists, such that guidelines now recommend the use of NOACs in preference over vitamin K antagonists. There are important opportunities to improve the management of NVAF outcomes for patients with NVAF by applying evidence-based guidelines for stroke prevention. Growing experience with NOACs in the MENA region will help guide patient selection and elucidate optimal dosing strategies to maximize the clinical benefits of the NOACs.

Severe aortic regurgitation complicating Takayasu's arteritis.

We present an uncommon case of a 48-year-old female patient with symptomatic presentation of a severe aortic regurgitation with aneurysm of the ascending aorta and progressive dyspnea. Detailed investigation of laboratory tests and imaging identified Takayasu's arteritis (TA) as the underlying etiology. Computed tomography scan revealed complete occlusion of the right carotid artery as well as stenosis at the origins of left subclavian and vertebral arteries. In addition, cardiac magnetic resonance angiogram showed aneurysm at the proximal segment of right subclavian artery. Intervention with corticosteroids effectively diminished the need for immediate surgical intervention. Treating physicians should always consider differential diagnosis of TA in the presence of atypical clinical findings in all patients with cardiac problems especially when there is valve involvement.

Implantable cardioverter-defibrillator insertion in congenital heart disease without transvenous access to the heart.

Sudden cardiac death is the leading cause of mortality in adults with complex congenital heart disease. Challenges to implanting cardioverter-defibrillators (ICDs) may arise as a result of vascular or intracardiac access issues. For example, conduits may divert systemic venous return to extracardiac structures such as pulmonary arteries or tunnels. Creative approaches to ICD implantation have previously involved subcutaneous arrays, often associated with thoracotomy to implant intrathoracic coils. We describe a patient with complex congenital heart disease and no transvenous access via the superior vena cava in whom ICD implantation involved placement of a coil within the azygos vein.