Peak oxygen uptake and metabolic equivalents explained by six-minute walk test: A prospective observational study in predicting heart failure patient readmission.

Background: Current statistics indicate that the overall cost of heart disease exceeds IDR 6.67 trillion per year. This growing concern has led researches on heart failure patient readmission in developing countries, and opened discussions on tactics to suppress hospital readmission rates. This study assesses the potential of VO2max and METs obtained from the 6-min walk test in predicting heart failure patient readmission. Methods: This seven-month prospective cohort study recruited patients with heart failure which then underwent the 6-min walk test before discharged. Walking distance, estimated VO2 max, and METs were calculated and recorded. Patients were then followed-up for 3 months to track readmissions under the same diagnosis during the research period. The correlation between VO2max and METs with patient readmission was assessed. Results: A total of 93 samples were included in this study. The results demonstrated that VO2max and METs correlate with incidence of heart failure readmission ≤30 days post discharge, with VO2max showing a moderate ability to predict patient readmissions with a cut-off of 14.5 mL/kgBW/minute (C = 0.750, p < 0.001), while METs showed a weak ability to predict readmissions with a cut-off of 3.8 (C = 0.743, p < 0.001). Conclusions: VO2 max and METs values acquired from 6MWT examination correlates with heart failure patient readmission ≤30 days. This knowledge can be used to prevent increased readmission rates, therefore hoping that it will be able to reduce the burden of treatment costs on heart failure patients.

Utility of Oral Quinine Sulfate for the Treatment of Brugada Syndrome Presenting as Electrical Storm in Remote Areas: Resilience in the COVID-19 Era.

Electrical storm is a malignant presentation of Brugada syndrome (BrS). Pharmacologic antiarrhythmic therapy is mandatory for this condition, followed by implantation of an implantable cardioverter-defibrillator to prevent sudden cardiac death. We report a case of a BrS patient presenting with electrical storm in a remote area. A referral to tertiary healthcare services was turned down due to the capacity demands of COVID-19 cases. Oral quinine was used as a bailout therapy and successfully maintained the arrhythmia suppression. Our case confirms that quinine is a reliable option to suppress electrical storm in BrS.

L'orage rythmique est une manifestation néfaste du syndrome de Brugada (SBr). Une pharmacothérapie antiarythmique s'avère incontournable dans ce contexte et doit être suivie de l'implantation d'un défibrillateur cardioverteur afin de prévenir la mort subite par arrêt cardiaque. Nous présentons le cas d'un patient atteint du SBr ayant subi un orage rythmique dans une région éloignée. Son orientation vers des services de soins de santé tertiaires a été refusée en raison de la mobilisation des ressources par les cas de COVID-19. Un traitement de sauvetage par la quinine administrée par voie orale a été instauré et a permis de maintenir la suppression des arythmies. Le cas de ce patient confirme que la quinine représente une option fiable pour arrêter un orage rythmique chez un patient atteint du SBr.

Provocative testing using low dose oral flecainide for diagnosis of Brugada syndrome: a report of two cases.

Background: Brugada syndrome (BrS) is a genetic disease characterized by coved ST-segment elevation in the right precordial leads that predispose to life-threatening ventricular tachyarrhythmia. The electrocardiographic signature is dynamic and often concealed but can be unmasked by potent sodium channel blockers such as Flecainide. Some studies have evaluated the effectivity of oral Flecainide 400 mg for provocative testing, but clinical utility of lower dose Flecainide (300 mg) has never been documented. Case summary: These two cases illustrate the effectiveness of low dose oral Flecainide to unmask Brugada electrocardiographic pattern. In our patients, diagnostic type 1 electrocardiography started to develop 30 min after drug administration and reached maximal positivity at 3.5-4.5 h. No atrioventricular block or ventricular arrhythmia was observed during the procedures. Discussion: A potent sodium channel blocker facilitates marked reduction of the right ventricle epicardial action potential, which creates a transmural voltage dispersion and manifests as an ST elevation in the right precordial leads. Time to positivity was comparably rapid, and time to maximal ST-elevation appeared close to peak plasma level of Flecainide (ranging from 1 to 6 h). Although asymptomatic patients have a low rate of adverse cardiac events, it is crucial to inform patients to avoid various modulators and precipitating factors that could trigger malignant arrhythmias.

Cardiac metastasis of triple-negative breast cancer mimicking myxoma: A case report.

INTRODUCTION: Metastatic heart tumors are rare, occurring in 1.5-20% of cancer patient autopsies. Lymphoma, melanoma, leukemia, and carcinomas of the lung, esophagus, and breast are the most prevalent causes of these metastases, although they can originate from any malignant tumor. Here we report a case of triple-negative breast cancer with cardiac metastasis mimicking myxoma. PRESENTATION OF CASE: A 39-year-old woman presented at the emergency department with shortness of breath. Vital signs were hypotension and tachypnea. There were coarse crackles at the bases of both lungs. Electrocardiography results showed a normal sinus rhythm. Chest X-ray revealed cardiomegaly with signs of pulmonary edema. Echocardiography revealed a large left atrial (LA) mass protruding to the mitral valve and attached to the interatrial septum during diastole. The patient was diagnosed with cardiogenic shock, acute kidney injury, elevated liver enzymes, and an LA mass. Surgical excision through median sternotomy was planned. Intraoperatively, an LA mass was found. The histopathology evaluation showed an LA mass with invasive ductal carcinoma of metastatic breast tumors. Immunohistochemistry (IHC) confirmed the diagnosis of triple-negative breast cancer that had metastasized to the heart. Postoperative echocardiography confirmed complete excision of the tumor. DISCUSSION: Breast cancer that has metastasized to the heart is uncommon. This patient was referred to the surgical oncology section for the treatment of triple-negative breast cancer with cardiac metastasis. CONCLUSION: A heart mass should be suspected of having metastasized if the patient has a history of malignancy, even if it occurred several years earlier.

Left atrial reverse remodeling improves sinus restoration following mitral valve replacement: A case report.

INTRODUCTION: Mitral stenosis is one of the most common abnormalities in rheumatic heart disease (RHD). These patients often experience atrial fibrillation, due to left atrial dilatation, causing a high risk of thromboembolic events; rhythm or heart rate control are thus important treatment strategies. In patients undergoing surgery, sinus rhythm restoration is not fully understood, and not all surgical patients return to sinus rhythm. We report an adult woman with mitral regurgitation who experienced sinus restoration after mitral valve replacement (MVR) surgery. CASE PRESENTATION: A 44-year-old woman presented with chief complaints of orthopnea and shortness of breath during activity for 2 months. Electrocardiography (ECG) revealed atrial fibrillation with normal ventricular response, and echocardiography showed severe mitral stenosis with Wilkins score of 10 (3-2-3-2), moderate mitral and aortic regurgitation due to RHD, moderate tricuspid regurgitation with probable pulmonary hypertension, normal left ventricular systolic function, ejection fraction of 60.5% (biplane). MVR surgery was performed using a mechanical mitral valve. Postoperative ECG found sinus rhythm and first-degree AV block. Postoperative echocardiography found a decreased left Atrial volume index of 70.8 mL/m2, indicating further remodeling of the patient's heart. CONCLUSION: Sinus restoration sometimes occurs in patients after MVR. The correction procedure causes minimal anatomical changes, particularly the loss of non-conductive and pathological tissue, followed by hemodynamic changes that eventually lead to the left atrial reverse remodeling mechanism.

Park Algorithm as Predictor of Premature Ventricular Contraction Origin in Three-Dimensional Mapping Electrophysiological Studies.

PURPOSE: In the past few years, premature ventricular contraction (PVC) has attracted immense attention, both in patients with or without structural heart disease. Despite the technological advancement, no guiding tools are currently available to assist in the prediction of origin of PVC using a 12-lead electrocardiogram (ECG) before electrophysiology and ablation procedures. Park and co-workers compiled the existing algorithms for the morphology of ECG from the literature and generated a single algorithm based on specific features of ECG for the prediction of PVC origin. The Park algorithm is limited to idiopathic PVC and has not been evaluated clinically. In the present study, the Park algorithm was used to predict PVC origin in patients with or without structural heart disease and compared with the gold standard examination based on three-dimensional electrophysiological mapping studies. PATIENTS AND METHODS: A cross-sectional study employing ECG data and electrophysiology study (EPS) reports from patients' medical records at Integrated Heart Center Wahidin Sudirohusodo Hospital, Makassar, Indonesia was conducted. The study was performed from April 2018 to June 2019 with a total of 31 samples; however, four samples were excluded during the EPS. RESULTS: In the present study, the incidence of structural heart disease was 45.2%. The suitability of the Park algorithm for electrophysiological evaluation was 85.2%, both in the case of PVC with and/or without structural heart disease. The prediction of the origin of PVC in the right or left heart using the Park algorithm showed a sensitivity of 95%, specificity of 100%, positive predictive value of 100%, negative predictive value of 87.5%, and accuracy of 96%. CONCLUSION: The findings of the study suggest significant accuracy of the Park algorithm in the prediction of location of origin of PVC. High sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the Park algorithm highlight its suitability to be used for determining the location of PVC origin in the right or left heart.

Cardiac Performance by Echocardiography, Cardiovascular Biomarker, Kidney Function, and Venous Oxygen Saturation as Mortality Predictors of Septic Shock.

BACKGROUND: cardiac function in patients with septic shock at the cellular level can be assessed by measuring troponin I and NT Pro BNP levels. Venous oxygen saturation is measured to evaluate oxygen delivery and uptake by organ tissue. Our study may provide greater knowledge and understanding on pathophysiology of cardiovascular disorder in patients with septic shock. This study aimed to evaluate the roles of echocardiography, cardiovascular biomarkers, venous oxygen saturation and renal function as predictors of mortality rate in patients with septic shock. METHODS: this is a prospective cohort study in patients with infections, hypotension (MAP < 65 mmHg) and serum lactate level of > 2 mmol/L. On the first and fifth days, septic patients underwent echocardiography and blood tests. Statistical analysis used in our study included t-test or Mann-Whitney test for numeric data and chi-square test for nominal data of two-variable groups; while for multivariate analysis, we used Cox Regression model. RESULTS: on 10 days of observation, we found 64 (58%) patients died and 47 (42%) patients survived. The mean age of patients was 48 (SD 18) years. Patients with abnormal left ventricular ejection fraction (LVEF) had 1.6 times greater risk of mortality than those with normal LVEF (RR 1.6; p = 0.034). Patients with abnormal troponin I level showed higher risk of mortality as many as 1.6 times (RR: 1.6; p = 0.004). Patients with impaired renal function had 1.5 times risk of mortality (RR 1.5; p = 0.024). Patients with abnormal troponin I level and/or impaired renal function showed increased mortality risk; however, those with normal troponin I level and impaired renal function also showed increased mortality risk. Multivariate analysis revealed that left ventricular ejection fraction and troponin I level may serve as predictors of mortality in patients with septic shock. (HR 1.99; 95% CI: 1.099  ̶  3.956 ; p = 0.047 and HR: 1.83 ; 95%CI: 1.049  ̶ 3,215 ; p = 0.043). CONCLUSION: left ventricular ejection fraction and biomarkers such as troponin I level are predictors of mortality in septic shock patients.

Pregnancy-related conditions and premature coronary heart disease in adult offspring.

OBJECTIVE: To investigate the association between complications during pregnancy and premature coronary heart disease in adult offspring. METHODS: We conducted a population-based case-control study of 153 Indonesian patients with a first acute coronary syndrome (ACS) (age ≤55 years) and 153 age-matched and sex-matched controls. Data on complications during pregnancy (high blood pressure, preterm delivery) and maternal infections in pregnancy were obtained, together with sociodemographic data, clinical profiles, laboratory measurements and adulthood cardiovascular disease (CVD) risk factors at hospital admission or enrolment. Conditional logistic regression was performed to assess the association between overall pregnancy complications, and specific groupings of complications and premature ACS. RESULTS: Pregnancy-related hypertension and infection were more common in mothers of cases than controls. Pregnancy complications were associated with premature offspring ACS (OR 2.9, 95% CI 1.4 to 6.0, p=0.004), and the association persisted in fully adjusted analyses (ORadjusted 4.5, 1.1 to 18.1, p=0.036). In subgroup analyses, pregnancy-related high blood pressure (ORadjusted 5.0, 1.0 to 24.7, p=0.050) and maternal infections (ORadjusted 5.2, 1.1 to 24.2, p=0.035) were associated with offspring ACS. CONCLUSIONS: Offspring of mothers with complications during pregnancy have an increased risk for premature ACS in adulthood, which may be of particular relevance in populations in transition, where the incidence of both pregnancy-related morbidity and CVD are high.