Comparison of Patients' Phenotypes, Guideline-Directed Recommendations Compliance and Rates of Cardiotoxicity between Caribbean and United States Cardio-oncology Programs.

Background: Little is known about the characteristics of oncological patients, cancer therapy-induced cardiotoxicity, and guidelines-directed interventions in the Caribbean; analysis of cardio-oncology services may shed light on this and clarify links between ethnicity, cultural, and local socioeconomic factors. Objectives: This study compared patients' phenotypes, adherence to guidelines recommendations, and patterns of cardiotoxicity between two cardio-oncology programs: one in the Dominican Republic (DR) and the other in Chicago IL, United States (US). Methods: Patients being considered for or treated with potentially cardiotoxic drugs were followed before, during, and after chemotherapy through both cardio-oncology clinics, where we recorded and compared clinical, demographic, and echocardiographic data. Results: We studied 597 consecutive patients, 330 (55%) from the DR and 267 (45%) from the US. DR vs. US mean age 55± 13/52 ± 13 years; female 77/87% (p < 0.001); breast cancer 57/73% (p < 0.001); treated with anthracyclines + taxanes 47/40% (p = 0.151); monoclonal antibodies + taxanes or platins 37/45% (p < 0.001). Cardiotoxicity DR vs. US occurred in 15/7% (p = 0.001); multivariate logistic regression (OR 2.29; 95% CI, 1.31-3.99; p < 0.005) did not identify age >60, HTN, DM, BMI, tobacco or chemotherapy as predictors. Compliance with ASCO guidelines was similar among both cohorts. Conclusion: Compared to the US cohort, the Caribbean cohort of cancer patients has similar rates of CV risk factors but a higher likelihood of developing drug-induced LV dysfunction. Programs' compliance with ASCO guidelines was equivalent. While further research is needed to ascertain regional variations of cardiotoxicity, these findings underline the relevance of cardio-oncology services in nations with limited resources and high CV risk.

Cardiopulmonary Imaging Utilization and Findings among Hospitalized COVID-19 Patients in Latin America: (From "RIMAC: Registry IMAging Cardiopulmonary among Hospitalized COVID-19 Patients in LATAM").

Objectives: Describe the use and findings of cardiopulmonary imaging-chest X-ray (cX-ray), echocardiography (cEcho), chest CT (cCT), lung ultrasound (LUS), and/or cardiac magnetic resonance imaging (cMRI)-in COVID-19 hospitalizations in Latin America (LATAM). Background: There is a lack of information on the images used and their findings during the SARS-CoV-2 pandemic in LATAM. Methods: Multicenter, prospective, observational study of COVID-19 inpatients, conducted from March to December 2020, from 12 high-complexity centers, in nine LATAM countries. Adults (>18 years) with at least one imaging modality performed, followed from admission until discharge and/or in-hospital death, were included. Results: We studied 1,435 hospitalized patients (64% males) with a median age of 58 years classified into three regions: Mexico (Mx), 262; Central America and Caribbean (CAC), 428; and South America (SAm), 745. More frequent comorbidities were overweight/obesity, hypertension, and diabetes. During hospitalization, 58% were admitted to the ICU. The in-hospital mortality was 28%, and it was highest in Mx (37%).The most frequent images performed were cCT (61%), mostly in Mx and SAm, and cX-ray (46%), significant in CAC. The cEcho was carried out in 18%, similarly among regions, and LUS was carried out in 7%, with a higher frequently in Mx. Abnormal findings on the cX-ray were peripheral or basal infiltrates, and in cCT abnormal findings were the ground glass infiltrates, more commonly in Mx. In LUS, interstitial syndrome was the most abnormal finding, predominantly in Mx and CAC.Renal failure was the most prevalent complication (20%), predominant in Mx and SAm. Heart failure developed in 13%, predominant in Mx and CAC. Lung thromboembolism was higher in Mx while myocardial infarction was in CAC.Logistic regression showed associations of abnormal imaging findings and their severity, with comorbidities, complications, and evolution. Conclusions: The use and findings of cardiopulmonary imaging in LATAM varied between regions and had a great impact on diagnosis and prognosis.

Physicians' perceptions on the impact of COVID-19 in coronary artery disease diagnostic imaging and treatment: A Latin America survey. For the Society of Cardiovascular Imaging of the Inter-American Society of Cardiology.

Background: Services during the pandemic were severely restricted, public reluctance to seek medical assistance rose, with a reduction of diagnostic and therapeutic modalities use in coronary artery disease (CAD). However, information about perceived barriers of care among cardiologists is limited. We aim to explore these barriers diagnostic and treatment modalities of CAD in Latin America during the pandemic. Methods: An anonymous Google form 12 closed-questions survey was conducted between November 2020 to January 2021. Latin American cardiologists members of the Imaging Society (SISIAC) of the Inter-American Society of Cardiology (SIAC) were reached by email and social media. Results: Differences were found in relation to patients' perceived reluctance to undergo testing, particularly in South America and inpatient care (p < 0.05). Respondents' perceived barriers in the use of CV tests were higher in South America (p < 0.05) and related to public practice (p < 0.01). Barriers to the treatment of myocardial infarction were present in all regions (p < 0.05), and follow-up was influenced by COVID-19 in both public and private practices (p = 0.01). Conclusions:  Regardless of treatment and diagnostic approach (invasive or non-invasive) followed, according to physicians' perception, the pandemic significantly impacted the clinical management of CAD in the Latin American population, similar to the global situation.

Contemporary trends in surgical rheumatic valve disease in a Caribbean nation.

BACKGROUND: Clinical practice suggests that rheumatic heart disease (RHD) represents a significant public health challenge in the Caribbean region where advanced disease appears early often leading to surgical intervention. We aimed to determine the burden of RHD and type of procedure among patients undergoing valve surgery in the Dominican Republic (DR). METHODS: Demographic, clinical and procedural data of all subjects intervened between January 2014 and December 2018 were obtained including valve disorder, anatomic location and type of surgery. Correlation coefficients were used to assess yearly trends of RHD among the 7 cardiovascular surgical centers in the country. RESULTS: Of 1626 valvular surgeries performed, 733 (45%) corresponded to RHD; 55% female patients, age 50 ± 11 (6-72) years; involving mitral 458 (63%); mitral + aortic 139 (19%); aortic 105 (14%); mitral + tricuspid 31 (4%); 95% prosthetic replacement and 5% mitral/tricuspid repairs. Mean proportion of RHD valve procedures per center for the study period was 53 ± 34%. Age-adjusted analysis showed an overall upwards trend in RHD valvular surgery (mean annual increment of 50 ± 40%, P = 0.01). CONCLUSIONS: Despite inter-center variability, rates of surgical RHD in the DR increased during the last 5 years affecting a relatively young population. Mitral involvement was the predominant lesion and prosthetic replacement the leading procedure. These data may guide local and regional institutions and policy makers towards the implementation of cost-effective initiatives against RHD.

Right ventricle in heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure. While previously neglected, the right ventricle (RV) has sparked interest in recent years as a means for better understanding this condition and as a potential therapeutic target.Right ventricular dysfunction (RVD) is present in 4%-50% of patients with HFpEF. The RV is intimately connected to the pulmonary circulation, and pulmonary hypertension is commonly implicated in the pathophysiology of RVD. The development of RVD in HFpEF may also be driven by comorbidities, such as chronic obstructive pulmonary disease, obesity, obstructive sleep apnoea and atrial fibrillation. The evaluation of RVD is particularly challenging due to anatomical and structural factors, as well as unique physiological characteristics of this chamber like load and interventricular dependency. Fractional area change, tricuspid annular plane systolic excursion and tricuspid annular systolic velocity are commonly used measurements of RV function. Speckle tracking echocardiography and cardiac magnetic resonance (CMR) are also gaining attention as important tools for the assessment of RV structure, fibre deformation and systolic performance. Further research is needed to confirm the utility and prognostic significance of RV [18F]fluorodeoxyglucose (FDG) positron emission tomography imaging as FDG accumulation is suggested to increase with progressive RVD. Targeted pharmacotherapy with phosphodiesterase inhibitors, guanylate-cyclase stimulators, nitrates and inhaled inorganic nitrites have yet to demonstrate improvement in RVD, compelling the need for evaluation and discovery of novel pharmacological interventions for this entity.

Giant Right Atrial Abscess in a Premature Infant With Fungal Endocarditis in a Developing Country.

Although infective endocarditis rarely appears during infancy, fungal infections remain a concern in the preterm neonatal population as the result of compromised immunity, prolonged hospitalization, and invasive procedures. The increased awareness of fungal colonization and improvements in medical therapy have not reduced the high mortality rate of mycotic infections in premature newborns, especially in developing countries, and there is no consensus on the surgical timing to treat neonatal fungal endocarditis. We present the case of a two-month-old boy with a history of three weeks of hospitalization for prematurity. After being discharged, the patient developed symptomatic candidemia resulting from a large right atrial abscess obstructing the tricuspid valve; despite antifungal therapy, urgent surgical resection was required.

Cardiac Imaging in Systemic Diseases: What the Clinician should Know.

IMPORTANCE: Systemic diseases that affect the cardiovascular system constitute a diagnostic and therapeutic challenge for all specialists involved; imaging tools along with clinical suspicion play an essential role in their evaluation. These entities share neurological, immunological, renal, hematologic, oncologic, infectious and endocrine processes, all of which may have associated cardiac involvement. OBSERVATIONS: Recent advances in cardiac ultrasound, Computed Tomography (CT), cardiac Magnetic Resonance (CMR) and nuclear scintigraphy have impacted the management of these conditions when involving the heart since they provide valuable anatomical and functional information while avoiding the use of invasive techniques. For this review, bibliographic sources were gathered from diverse databases, including PubMed, Cochrane, EBSCO and Google Scholar, concentrating on English language publications dealing with the clinical use of these tools. CONCLUSION: Clinical suspicion should always guide the use of imaging since in many instances, these techniques only play a supportive role rather than representing a diagnostic gold standard. Early diagnosis is critical due to the fact that cardiac manifestations are commonly a late phenomenon.

Novel developments in stress cardiomyopathy: From pathophysiology to prognosis.

Stress cardiomyopathy (SC) is characterized by transient left ventricular (LV) wall motion abnormalities typically involving the apex with preserved basal contractility, chest discomfort, ST-T ischemic changes and elevated cardiac markers with normal or non-flow limiting coronary artery lesions. It represents an important differential diagnosis of Acute Coronary Syndromes caused by atherosclerotic vessel occlusion; most commonly, Tako-tsubo occurs in postmenopausal women after physical or emotional stress. While the exact mechanism of SC remains controversial, various hypotheses have been suggested concerning the vascular, central nervous and endocrine system participation where catecholamines, particularly epinephrine, seem to play a major role. Hormonal, genetic and psychiatric conditions may also define the risk of susceptibility in some groups affected by SC. Long-term survival data are limited with mortality occurring predominantly in the first year after diagnosis usually related to non-cardiac illnesses. Echocardiography promises to become a useful tool to correctly identify SC patients at high risk for complications.

Late bacterial endocarditis of an Amplatzer atrial septal device.

A 59-year-old male with an secundum atrial septal defect status post repair with an Amplatzer occluder in 2001 was admitted with sepsis and MRSA bacteremia. Transesophageal Echocardiography (TEE) showed presence of an overlying mobile echogenic structure on the left atrial surface of the device suggestive of a vegetation/infected thrombus. This is only the 3rd case description of late endocarditis involving the Amplatzer ASD closure device in an adult.

VO2 Max and anaerobic threshold in hypertension: a tissue Doppler study.

BACKGROUND: Hypertension can impair left ventricular (LV) relaxation causing shortness of breath and reduced exercise capacity, which may affect the clinical evaluation of the symptomatic hypertensive patient. In this study we used tissue Doppler imaging (TDI) to identify correlates of anaerobic threshold (AT) and maximum oxygen uptake (VO2 Max). Our goal was to assess the feasibility of TDI as a surrogate of functional capacity in hypertensive individuals. METHODS: We studied subjects without metabolic syndrome and with normal LV function (ejection fraction (EF) >50%). Traditional echocardiographic variables were obtained before and after a cardiopulmonary exercise test. Systolic (S) and diastolic (E'and A') myocardial velocities were measured at the basal septal (bs) and posterior (bp) walls. RESULTS: After multivariate analysis, resting E'bp (r =0.56, P < 0.002) and isovolumic relaxation time (IVRT) (r =-0.49, I < 0.03) correlated with VO2 Max, while A Valsalva correlated with AT (r =-0.46, P < 0.03). Peak stress E'/A'bp correlated with age and gender corrected METs (r =-0.63, P < 0.0004) and VO2 Max (r =-0.39, P< 0.04). CONCLUSIONS: Resting E'bp and peak stress E'/A'bp correlate with VO(2) Max in hypertensive patients. TDI may be an important tool when assessing symptoms in this population.

Usefulness of multislice computed tomographic coronary angiography to identify patients with abnormal myocardial perfusion stress in whom diagnostic catheterization may be safely avoided.

Computed tomographic angiography (CTA) has been validated for noninvasive assessment of coronary anatomy. The aim was to establish whether CTA could guide the use of invasive coronary angiography (ICA) in symptomatic patients with intermediate risk after myocardial perfusion stress imaging (MPSI). From April 2005 to February 2006, patients referred for CTA to a cardiology practice were entered into a database. Inclusion required symptoms suggestive of coronary artery disease and intermediate-risk MPSI. Subjects with intermediate risk after MPSI underwent CTA, and if severe stenosis or moderate stenosis matching a perfusion defect was found, ICA was performed. If appropriate, patients were then sent for revascularization. Clinical follow-up was completed until December 2006. Main outcome measures were number of patients sent for ICA, immediate revascularization after ICA, and adverse outcomes (death, myocardial infarction, and late revascularization). Four hundred twenty-one patients were included. Adequate diagnostic-quality images were obtained in 99%. After MPSI-CTA assessment, 78 patients (18.5%) were sent for ICA and 343 (81.5%) were medically managed. Follow-up was 15+/-3 months. In the group referred for ICA, there were 50 cases of immediate revascularization, 1 non-ST-segment elevation myocardial infarction, 1 death, and 5 patients requiring repeat ICA, 3 of whom underwent late revascularization. In the medically managed group, 6 patients required late ICA, 1 of whom underwent revascularization. In conclusion, in symptomatic patients with suspected coronary artery disease and intermediate-risk MPSI results, CTA can identify up to 80% of patients at low risk of events in whom ICA may be safely avoided. Additional studies assessing new technologies combining MPSI-CTA are needed to refine imaging strategies in these patients.

Recurrent strokes in a young patient with papillary fibroelastoma: a case report and literature review.

Since the introduction of echocardiography the diagnosis of papillary fibroelastomas (PFEs) in living patients has increased. They are second most common after myxomas representing 10% of cardiac tumors. The present case is of a patient with recurrent cerebrovascular accidents and documented protein S deficiency who continued to stroke despite adequate anticoagulation. Mitral valve PFE was suspected on echocardiography and confirmed at surgical excision. Two large studies published in the last decade describe the echocardiographic and clinical characteristics of PFEs which although are histologically benign, may present with a clinical course of devastating consequences owing to its strategic location within the cardiac structures. Echocardiography, particularly transesophageal echocardiography (TEE), provides the necessary anatomical resolution and detail to ascertain location, extent of involvement, and hemodynamic implications. Tissue diagnosis is based on characteristic histopathological features of avascular fronds lined by endothelial cells, containing varying amounts of elastin. The echocardiographic characteristics along with treatment options are reviewed.

Comparison of six-month outcomes and hospitalization rates in heart failure patients with and without preserved left ventricular ejection fraction and with and without intraventricular conduction defect.

Prolonged QRS duration (>120 ms), as a marker of ventricular dyssynchrony, is an independent predictor of mortality in systolic heart failure (HF). Little information exists about the characteristics of patients with preserved ejection fractions (EFs) and prolonged QRS (intraventricular conduction defects [IVCDs]). The electronic records of 334 consecutive patients hospitalized with acutely decompensated HF were reviewed. A significant number of patients hospitalized with decompensated HF had preserved EFs with IVCD. They had similar readmission and mortality rates compared with their systolic HF counterparts and higher rates compared with those with preserved EFs without IVCD. These findings and the resulting possible therapeutic interventions (resynchronization) need further analysis in a larger prospective cohort.