Nontuberculous Mycobacterial Infections Associated With Left Ventricular Assist Devices in 3 Patients.

Durable left ventricular assist devices (LVADs) provide circulatory support in patients with end-stage heart failure; however, complications include infection of the driveline exit site. Nontuberculous mycobacterial infections are rare in patients with LVADs, but they should be considered in those who have undergone device exchanges and have bacterial infections with driveline exit-site discharge but no fever or leukocytosis. We reviewed the charts of patients who had an LVAD implanted at our institution from January 2009 through December 2019, to identify those with a device-related nontuberculous mycobacterial infection. Collected data included patient demographics, premorbid conditions, infection type, previous device complications, treatment, and outcomes. We identified infections in 3 patients (mean age, 41 yr): Mycobacterium abscessus in 2 and M. chimaera in 1. All had a HeartMate II device and had undergone device exchanges for pump thrombosis or for driveline fault or infections. All presented with driveline exit-site discharge without fever or leukocytosis. The mean time between initial device implantation and diagnosis of a nontuberculous mycobacterial infection was 55 months. All 3 patients were treated with antibiotics and underwent localized surgical débridement; one underwent an additional device exchange. The M. abscessus infections disseminated, and both patients died; the patient with M. chimaera infection continued to take suppressive antibiotics. Nontuberculous mycobacterial infections are associated with high morbidity and mortality rates, warranting prompt diagnosis and treatment.

From Hip to Heart: A Comprehensive Evaluation of an Infiltrative Cardiomyopathy.

Infiltrative cardiomyopathies are an increasingly recognized cause of heart failure warranting systematic evaluation. Given overlap of clinical and imaging findings among etiologies of infiltrative cardiomyopathies, comprehensive evaluation, including a history and physical examination, advanced cardiac imaging, and sometimes endomyocardial biopsy, is required for diagnosis. We report a case of infiltrative cardiomyopathy in which endomyocardial biopsy confirmed diagnosis of cobalt-induced cardiomyopathy. The novel teaching points highlighted by this case report include identification of heavy-metal toxicity as a cause of infiltrative cardiomyopathy, and the outline of a diagnostic approach and management for cobalt-induced cardiomyopathy.

Le fait que les cardiomyopathies infiltrantes sont de plus en plus reconnues comme la cause de l'insuffisance cardiaque justifie une évaluation systématique. Puisque les résultats cliniques et d'imagerie se recoupent entre les étiologies des cardiomyopathies infiltrantes, l'évaluation exhaustive, y compris les antécédents et l'examen physique, les techniques avancées en imagerie cardiaque et parfois la biopsie endomyocardique, est nécessaire au diagnostic. Nous présentons un cas de cardiomyopathie infiltrante pour lequel la biopsie endomyocardique a permis de confirmer le diagnostic d'une cardiomyopathie induite par le cobalt. Parmi les points à enseigner illustrés dans cette observation, on cite la reconnaissance de la toxicité des métaux lourds comme une cause de cardiomyopathie infiltrante, et la vue d'ensemble de l'approche diagnostique et de la prise en charge de la cardiomyopathie induite par le cobalt.

Isolated Left Ventricular Metastasis from Renal Cell Carcinoma: Diagnostic and Therapeutic Dilemma.

BACKGROUND: The treatment of metastatic renal cell carcinoma (RCC) has been radically changed by the advent of tyrosine kinase inhibitors (TKIs). However, few reports have described their role in cardiac metastases. We present a case of a left ventricular metastasis from RCC that was managed with pazopanib therapy. CASE REPORT: A 74-year-old male with stage I RCC underwent right nephrectomy in 2004 and right lung metastasis resection in 2009. He was well till March 2016, when he presented with chest pain. Cardiac catheterization revealed a highly vascular mass in the apex. Cardiac magnetic resonance imaging revealed a left ventricular mass with full-thickness involvement of the myocardium, and the open cardiac biopsy was consistent with metastatic RCC. The patient was initially treated with pazopanib with response but later developed therapy-related side effects, and the dose was reduced. Due to tumor progression, he is currently on nivolumab instead and is stable. CONCLUSION: RCC with cardiac metastasis poses unique challenges with regard to diagnosis as well as treatment. The use of TKI therapy is associated with cardiotoxicity and has not been adequately studied in cardiac metastasis. Choosing the right treatment for this subgroup of patients continues to pose an ongoing dilemma.

The Untapped Potential of Tunneled Pleural Catheters.

BACKGROUND: Tunneled pleural catheters (TPCs) are routinely used for outpatient drainage of malignant pleural effusions, although use in recurrent pleural effusions resulting from nonmalignant conditions requires further evaluation. We hypothesized that TPCs could decrease inpatient admission rates for exacerbations of nonmalignant pleural effusions. METHODS: A retrospective chart review was done of patients with TPCs inserted for recurrent nonmalignant pleural effusions. Patients were set up with home care nursing support and catheter draining two to three times per week and were then followed on an outpatient basis until spontaneous pleurodesis and catheter removal. Data collection included demographics, comorbidities, and hospital admission rates relative to TPC placement as well as removal. RESULTS: Thirty-seven patients with recurrent, nonmalignant pleural effusions were enrolled (17 female and 20 male patients). Patients had comorbid conditions including hypertension (86%), chronic kidney disease (59%), congestive heart failure (67%), liver disease (11%), and malnutrition (22%), and most patients (89%) had multiples of these conditions. Total admissions for pleural effusion exacerbations decreased from 59 to 15 in the 1 year before and after TPC placement and from 42 to 6 in the respective 3-month periods (p < 0.0001). Six of the 37 patients still had TPCs in place; for the remaining 31 patients, admissions decreased from 60 to 9 in the 1-year periods before and after TPC removal and from 33 to 2 in the respective 3-month periods (p < 0.0001); no patients required subsequent pleural interventions. CONCLUSIONS: The study results support TPC placement in recurrent nonmalignant pleural effusions refractory to medical management as an effective and plausible management option.

High-risk percutaneous coronary intervention in a patient with a single coronary artery presenting as STEMI and cardiogenic shock.

Cardiogenic shock due to ST elevation myocardial infarction in a patient with a single coronary artery involving the sole vessel is a rare presentation. This can be clinically and angiographically challenging. Proper recognition of the topography of diseased vessels and a systematic guarded approach can lead to procedural success. We report a case of an 81-year-old woman who presented with chest pain followed by a near syncope associated with an acute myocardial infarction. Coronary angiography revealed a single proximally occluded right coronary artery and an anomalous left main coronary artery (originating from the proximal right coronary artery) and occluded distal left circumflex artery. The right coronary artery was successfully stented following predilation without compromising the anomalous left main origin. The flow in the chronically occluded left circumflex artery (originating from the anomalous left main) which was depended on the retrograde supply from right coronary artery through collaterals, was also re-established.

Cardiac troponin release following hybrid coronary revascularization versus off-pump coronary artery bypass surgery.

OBJECTIVES: Cardiac ischaemic marker release is associated with adverse clinical outcomes after cardiac surgery. We sought to compare the release of cardiac troponin I (cTnI) after hybrid coronary revascularization (HCR) with off-pump coronary artery bypass surgery (OPCAB). METHODS: Using data from a prospective single-centre registry, we compared cTnI measured at postoperative day 1 following one-stage HCR and OPCAB among patients with normal baseline cTnI. Multivariable linear regression analysis was used to adjust for variables that may have influenced cardiac marker release other than the used revascularization strategy. RESULTS: Sixty-five consecutive patients underwent elective HCR (n = 33) or OPCAB (n = 32). Overall, no differences were seen in comorbidities, CABG risk scores and the lesion-specific SYNTAX score. Procedural complications were lower (15.2 vs 34.4%, P = 0.072), but 30-day and 1-year clinical outcomes (death, myocardial infarction, and repeat revascularization) were similar between the two groups (3.0 vs 3.1% and 9.1 vs 6.2%, respectively). Post-procedural cTnI release measured at 24 h after surgery was significantly lower following HCR compared with OPCAB [ratio of upper reference level URL: median: 3.5, interquartile range (IQR): 0.8-9.1 vs 12.8, IQR: 6.9-21.8, P = 0.001]. After adjusting for potential confounders, HCR was associated, on average, with cTnI less than half (46%) compared with CABG (P <0.0001). CONCLUSIONS: HCR is associated with lower postoperative cTn release, compared with OPCAB. Further research into the clinical implications of this finding is warranted.

Modeling the interactions of herbal drugs to beta-ketoacyl ACP synthase of Mycobacterium tuberculosis H37Rv.

The present paper reports a bio-computational study carried out with the aim of understanding the binding mode of anti-TB herbal ligands onto the homology modeled structure of fatty acid synthase of Mycobacterium tuberculosis (M.tb) H37Rv. Sequence alignment of beta-ketoacyl ACP synthase (KAS) domain of the protein with other related KAS sequences of PDB database revealed high degree of sequence variation. However, the catalytic triad comprising of CHH (cys150-his279-his320) was found to be conserved in the KAS sequence of M.tb H37Rv. The tertiary structure of this protein predicted using genetic algorithm operator in the MODELLER package appeared to give a satisfactory structure for the purpose of studying ligand and substrate binding pockets on the protein. PDB templates complexed with ligands (citric acid and lauric acid) were used for model building. Docking studies carried out with different herbal ligands suggest that, aloe-emodin and nimbin are the best herbal candidates to replace the synthetic drugs 'thiolactomycin/cerulenin'.