Predicting the Severity and Outcome of Persistent Pulmonary Hypertension of the Newborn Using New Echocardiography Parameters.

To examine echocardiographic parameters correlation with clinical severity indices, Alveolar- arterial gradient (A-a gradient), oxygenation index and clinical outcomes in newborns with persistent pulmonary hypertension of the newborn (PPHN). Retrospective cohort study of 67 subjects, >35 weeks' gestation with the diagnosis of PPHN admitted to the University of Kentucky neonatal intensive care unit (NICU) between September 2014 and December 2016. High left ventricular end-systolic eccentricity index (EIs) correlates with the overall clinical severity of PPHN as it is associated with higher A-a gradient and oxygenation index (P = 0.0003 and P < 0.0001, respectively). Elevated EIs was also predictive for the use of inhaled nitric oxide and extracorporeal membrane oxygenation (P = 0.0004 and P < 0.0001, respectively). EIs value of >1.38 provides cutoff value as an objective marker for the need for extracorporeal membrane oxygenation. EIs can be used to assess clinical severity and outcomes and should be reported routinely. Further studies are warranted to confirm these results.

Determining the Safety of Radiofrequency Ablation in Cardiovascular Implantable Electronic Devices.

Radiofrequency catheter ablation (RFCA) is an effective treatment for arrhythmias. The effects of RFCA on cardiovascular implantable electronic devices (CIED) function have varied. We aim to study the effect of RFCA on device parameters and clinical outcomes in patients with CIED. We conducted a single-center retrospective cohort study between 2011 and 2018. Generator and lead parameters were compared pre- and post-ablation using paired sample t-test. The median follow-up interval for documentation of procedure-related complications and clinical outcomes was 8 weeks. We identified 119 eligible patients; whose mean age was 64.5 ± 11.91 years and 22 (18.4%) were females. Types of CIED include single-chamber implantable cardioverter defibrillators (8.93%), dual-chamber implantable cardioverter defibrillators (41.96%), and either dual-chamber or biventricular pacemakers (44.54%). Arrhythmias for which patients underwent RFCA include atrial fibrillation/atrial tachycardia (15.22%), atrial flutter (38.14%), atrioventricular node reentrant tachycardia (13.56%), and premature ventricular complex or ventricular tachycardia (20.34%). No statistically significant difference was observed in pre- and post-ablation: (1) atrial sensing thresholds, pacing thresholds, lead impedance; (2) right ventricle sensing and pacing thresholds; and (3) left ventricle pacing threshold and impedance. A decrease in right ventricle impedance after ablation (549.77 ± 173 ohm vs 507.40 ± 129.0 ohm, P-value <0.004) was observed. Zero complications or deaths were observed. In this single-center study, RFCA did not significantly impact CIED function and was not associated with short-term complications. However longer follow-up is required to confirm these findings.

Early Versus Late Catheter Ablation of Atrial Fibrillation and Risk of Permanent Pacemaker Implantation in Patients With Underlying Sinus Node Dysfunction.

Background Atrial fibrillation (AF) is associated with anatomical and electrical remodeling. Some patients with AF have concomitant sick sinus syndrome and may need permanent pacemaker (PPM) implantation. Association between catheter ablation of AF timing and need for PPM in sick sinus syndrome has not been assessed. Methods and Results We used pooled electronic health data to perform retrospective cross-sectional analysis of 66,  595 patients with AF and sick sinus syndrome to assess the need of PPM implantation temporally, with AF performed divided into earlier within 5 years (group 1), 5 to 10 years (group 2), or beyond 10 years (group 3) of diagnosis. PPM implantation was lowest among those who had catheter ablation within 5 years of sick sinus syndrome diagnosis: group 1 versus group 2 (18.15% versus 27.21%) and group 1 versus group 3 (18.15% versus 27.22%). Interestingly, there was no difference in risk of PPM between group 2 and group 3 (27.21% versus 27.22%; odds ratio [OR], 1.00 [95% CI, 0.85-1.20]). Conclusions Even after controlling known risk factors that increase the need for pacemaker implantation, timing of AF ablation was the strongest predictor for need for PPM. Patients adjusted OR of PPM was lower if patients had catheter ablation within 5 years of diagnosis compared with later than 5 years (adjusted OR, 0.64 [95% CI, 0.59-0.70]).

Gender, ethnic, and socioeconomic differences in access to catheter ablation therapy in patients with atrial fibrillation.

Introduction: Female patients, patients from racial minorities, and patient with low socioeconomic status have been noted to have less access to catheter ablation for atrial fibrillation. Methods: This is a cross-sectional, retrospective study using a large population database (Explorys) to evaluate the gender, racial and socioeconomic differences in access of catheter ablation therapy in patient with atrial fibrillation. Results: A total of 2.2 million patients were identified as having atrial fibrillation and 62,760 underwent ablation. Females had ablation in 2.1% of cases while males received ablation in 3.4% of cases. Caucasians had ablation in 3.3% of cases, African Americans in 1.5% of cases and other minorities in 1.2% of cases. Individuals on medicaid underwent ablation in 1.6% of cases, individuals on medicare and private insurance had higher rates (2.8 and 2.9%, respectively). Logistic regression showed that female patients (OR 0.608, CI 0.597-0.618, p < 0.0001), patients who are African American (OR 0.483, CI 0.465-0.502, p < 0.0001), or from other racial minorities (OR 0.343, CI 0.332-0.355, p < 0.0001) were less likely to undergo ablation. Patient with medicare (OR 1.444, CI 1.37-1.522, p < 0.0001) and private insurance (OR 1.572, CI 1.491-1.658, p < 0.0001) were more likely to undergo ablation. Conclusion: Female gender, racial minorities, low socioeconomic status are all associated with lower rates of catheter ablation in management of atrial fibrillation.

Septal myectomy complicated by an embolic stroke in a patient with hypertrophic cardiomyopathy: a case report.

BACKGROUND: Hypertrophic cardiomyopathy is estimated to affect 1 out of every 500 adults in the USA. One of its main complications is left ventricular outflow obstruction, which may require surgical septal myectomy in severe cases. We report a rare complication of postoperative septal akinesis leading to thrombus formation presenting as an acute ischaemic stroke. CASE SUMMARY: A 48-year-old woman presented with acute stroke 2 years after surgical septal myectomy for hypertrophic obstructive cardiomyopathy. Diagnostic workup identified an intraventricular thrombus arising in the left ventricular outflow tract (LVOT). After comprehensive evaluation, it was determined that the thrombus development was a complication of the prior septal myectomy causing focal septal akinesis. Treatment with anticoagulation resulted in improvement of neurological symptoms and resolution of the intraventricular thrombus. DISCUSSION: This case illustrates the rarity and unusual presentation of an intracardiac thrombus that arises from septal myectomy site. A thrombus arising in the LVOT, which is characterized by high gradient laminar flow, is highly unusual. This suggests microscopic and macroscopic alteration in the ventricular septal wall structure, as evident by the septal wall akinesis seen on echocardiography. Recognition of this complication is critical to the selection of appropriate anticoagulation as secondary stroke prevention in these patients.

The incidence of COVID-19 in patients with metabolic syndrome and non-alcoholic steatohepatitis: A population-based study.

BACKGROUND: The novel coronavirus disease (COVID-19) emerged from China in 2019 and rapidly spread worldwide. Patients with metabolic comorbid conditions are more susceptible to infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Metabolic syndrome is a constellation of interlinked metabolic risk factors that predispose patients to increased risk of complications. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and non-alcoholic steatohepatitis (NASH) is the aggressive form of NAFLD. OBJECTIVE: The aim of this study is to determine the relationship between metabolic syndrome components and the risk of COVID-19. METHODS: We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED-CT), we identified adults with the diagnosis of metabolic syndrome and its individual components from 1999 to 2019. We included patients with the diagnosis of COVID-19 from December 2019 to May 2020. Comorbidities known to be associated with COVID-19 and metabolic syndrome such as obesity, diabetes mellitus, dyslipidemia, smoking, male gender, African American, and hypertension were collected. Univariable and multivariable analyses were performed to investigate whether metabolic syndrome or its individual components are independently associated with the risk of COVID-19. RESULTS: Out of 61.4 million active adult patients in the database, 8885 (0.01%) had documented COVID-19. The cumulative incidence of COVID-19 was higher if metabolic syndrome was the primary diagnosis (0.10% vs 0.01%, OR 7.00 [6.11-8.01]). The adjusted odds (aOR) of having COVID-19 was higher in patients if they were African Americans (aOR 7.45 [7.14-7.77]), hypertensive (aOR 2.53 [2.40-2.68]), obese (aOR 2.20 [2.10-2.32]), diabetic (aOR 1.41 [1.33-1.48]), hyperlipidemic (aOR 1.70 [1.56-1.74]), or diagnosed with NASH (aOR 4.93 [4.06-6.00]). There was a slight decrease in the adjusted odds of having COVID-19 in males as compared to females (aOR 0.88 [0.84-0.92]). CONCLUSION: The incidence of COVID-19 in patients with metabolic syndrome is high. Among all comorbid metabolic conditions, NASH had the strongest association with COVID-19.

FIB-4 Regression With Direct-Acting Antiviral Therapy in Patients With Hepatitis C Infection: A Safety-Net Hospital Experience.

Background: Liver fibrosis stage determines the risk of morbidity and mortality from chronic hepatitis C virus (HCV) infection. The majority of HCV-infected patients are underserved and have other comorbid conditions that lead to more progressive liver disease such as cirrhosis and hepatocellular carcinoma. Safety net hospitals are the prime location to treat these patients. Direct acting antiviral (DAA) agents are highly effective in virus eradication. Aim: We aimed to evaluate the effect of treatment with DAAs on FIB-4 index. Methods: We identified 343 patients who initiated HCV treatment with DAAs from 2016 to 2018 and achieved a sustained virologic response (SVR) in Metrohealth Medical Center, a safety net hospital system. We compared the severity of hepatic fibrosis before and 1 year after SVR was attained. We evaluated whether the presence of other comorbid conditions influenced liver fibrosis regression. All analyses were performed using SAS software. Results: There was a statistically significant drop in mean FIB-4 score from baseline to post-SVR (3.47 ± 2.84 vs. 2.28 ± 1.60, P < 0.001). One hundred seventeen patients had baseline FIB-4 scores ≥3.25, 56% had FIB-4 scores <3.25 after SVR. Alcohol use disorder was associated with a higher baseline FIB-4 score compared to low level drinking (3.85 ± 0.20 vs. 3.15 ± 0.16). These patients showed greater improvement in FIB-4 scores after treatment when compared to those without alcohol use disorder (1.44 ± 0.15 vs. 0.97 ± 0.13, P = 0.02). Conclusion: FIB-4 index is a useful non-invasive tool for monitoring fibrosis regression after antiviral therapy. Patients with a history of alcohol abuse had the greatest reduction in FIB-4 score post-SVR.

The Risk of Cerebrovascular Accidents in Inflammatory Bowel Disease in the United States: A Population-Based National Study.

BACKGROUND: Inflammatory bowel disease (IBD) has been associated with an increased risk of cardiovascular events, but the risk of cerebrovascular accidents (CVA) remains unknown. Hypercoagulability and systemic inflammation are two proposed mechanisms by which the presence of IBD might lead to the development of CVA. OBJECTIVE: To assess the risk of CVA in patients with IBD compared to those without IBD with known traditional risk factors for CVA. METHODS: We reviewed data from a large commercial database (Explorys, IBM) that aggregated records from 26 health-care systems nationwide. Using systemized nomenclature of medicine - clinical terms, we identified adult patients diagnosed with IBD (ulcerative colitis or Crohn's disease) between September 1994 and September 2019. We then examined the risk of CVA in these patients. Known risk factors such as age ≥65-years old, diabetes mellitus (DM), hypertension (HTN), female gender, atrial fibrillation (Afib) were collected. A univariate binary logistic model was constructed using CVA as the dependent variable and other variables as independent variables. To adjust for possible confounding, a multivariable model adjusting for all covariates was created to test for CVA. RESULTS: A total of 52,176,550 patients were included in this analysis, and 261,890 had IBD. The prevalence of CVA was higher in IBD patients compared to non-IBD patients (6.24% versus 0.48%, p <0.0001). The univariate binary logistic regression showed 13.7 times higher odds of having CVA in IBD patients than without IBD (odds ratio (OR) 13.74, p <0.0001). In multivariate binary logistic regression, after adjusting for traditional risk factors for CVA (Afib, HTN, female gender, DM, age ≥65 years), odds ratio of CVA in IBD patients remained significantly higher (OR 8.07, 95% CI: 7.9-8.2, p<0.0001). CONCLUSION: In our large cohort of patients, IBD appears to be an independent risk factor for CVA. Further prospective studies are needed to understand the underlying mechanisms by which IBD increases the risk of CVA. This may lead to early identification and intervention to reduce the risk of CVA in this highly heterogeneous group of patients.

Azithromycin-Induced Thrombocytopenia: A Rare Etiology of Drug-Induced Immune Thrombocytopenia.

Drug-induced thrombocytopenia requires a high suspicion for diagnosis and a broad investigation to exclude other etiologies of low platelets. Cessation of the offending agent often results in recovery of platelet counts. Many medications are known to cause a degree of thrombocytopenia. We present a rare case of severe thrombocytopenia associated with administration of azithromycin.

Deep Vein Thrombosis Complicated by Spontaneous Iliopsoas Hematoma in Patient with Septic Shock.

BACKGROUND Spontaneous retroperitoneal hemorrhage (SRH) is a rare and difficult-to-diagnose entity. It is not associated with trauma, pathology, or iatrogenic manipulations. Few cases have been reported, with the only precipitating factor recognized being bleeding diatheses such as anticoagulation states, inherited coagulopathies, and hemodialysis. However, none of these have been described in combination with septic shock, which itself is associated with platelet dysfunction, coagulation dysfunction, and vasculopathy. CASE REPORT Our case involves an elderly man presenting with altered mental status of unknown etiology, in addition to hemodynamic instability, presumably due to septic shock, without any overt signs of bleeding. After his initial exam revealed lower-extremity edema and decubitus ulcers, a venous Doppler was performed, which revealed extensive deep vein thrombosis. It was unknown whether the sepsis or DVT occurred first. Therapeutic anticoagulation with heparin was subsequently started. On hospital day 4, a CT abdomen with contrast identified retroperitoneal hematoma after the patient's hemoglobin lowered without any overt signs of bleeding. The diagnosis of spontaneous retroperitoneal hematoma was one of exclusion and posed a therapeutic dilemma (conservative versus invasive management). CONCLUSIONS Sepsis-related coagulopathy and heparin use in an elderly patient predisposed him to an iliopsoas hematoma. In this case, conservative management with reversal of anticoagulation and blood transfusion was sufficient to stabilize the patient.