Atypical Stress Cardiomyopathy and the Need for Multidisciplinary Care.

Reverse takotsubo cardiomyopathy is a rare variant of the classic stress-induced takotsubo cardiomyopathy. It is associated with transient left ventricular (LV) systolic dysfunction characterized by basal hypokinesis and apical hyperkinesis. We present a case of a 27-year-old woman who presented to an outside facility for a scheduled cesarean section and developed perioperative chest tightness, hypoxemia, and hypotension. Her electrocardiogram (ECG) showed sinus rhythm with marked ST segment depressions in leads V4-V6. High sensitivity troponin was elevated to 474 ng/L. Transthoracic echocardiography revealed an LV ejection fraction of 52% (Simpson's) with hypokinesis of the basal myocardial segments and hyperdynamic systolic function of the apical segments. Subsequent coronary angiography showed angiographically normal epicardial coronaries. Left ventriculography showed ballooning of the basal segments with apical hyperkinesis. She was subsequently diagnosed with reverse takotsubo cardiomyopathy and managed conservatively with beta-blockers. In this case, we highlight the need for collaboration between the cardiology and obstetric teams for tailored management strategies to ensure the well-being of both mother and baby.

Severe COVID-19 post pregnancy complicated by acute thromboemboli resulting in ST-elevation myocardial infarction - A case report.

Introduction: It has been shown that pregnancy can cause alterations in the severity of COVID-19 infection. We demonstrate an immediate post-partum patient diagnosed with severe COVID-19 and subsequently developed acute thrombosis of coronary artery.Case Summary: 35-year-old female unvaccinated for COVID-19 presented in labor and delivered on the same day. Several hours later, she was found to be in respiratory distress and tested positive for COVID-19. On day 7, computerized tomography (CT) of chest revealed bilateral pneumonia and pneumomediastinum. On day 8, she developed chest pain with electrocardiogram (EKG) showing inferior STelevations with troponin I of 0.6 ng/mL. She was intubated for airway protection and emergent diagnostic angiogram revealed thrombus occlusion of the third right posterolateral segment that resulted in thrombolysis in myocardial infarction (TIMI) 0 flow without evidence of underlying atherosclerotic disease in the remaining vessels. Intracoronary IIb/IIIa inhibitor was administered. Arterial blood gas in the lab revealed profound hypoxia despite being on 100% inspired oxygen. Multidisciplinary decision was made to cannulate patient for venovenous extracorporeal membrane oxygenation (ECMO) to treat severe COVID-19 pneumonia. She was finally decannulated from ECMO on day 65. After prolonged hospital stay, she eventually recovered and was discharged to rehabilitation.Conclusions: The center for disease control (CDC) surveillance has reported that pregnant patients with COVID-19 are more likely to require invasive ventilation and ECMO, and die given the immunological changes during pregnancy. Hypercoagulable state caused by combination of pregnancy and COVID-19 resulting in coronary thrombosis is rarely described in literature, our case demonstrated the paucity of this phenomenon.

Orthodeoxia Platypnea Syndrome in the Setting of Cholangiocarcinoma: A Case Report.

Platypnea-orthodeoxia syndrome is a rare cause of positional hypoxemia and dyspnea. We present the case of a 54-year-old man with right-to-left shunting through a patent foramen ovale in the setting of metastatic cholangiocarcinoma resulting in platypnea-orthodeoxia syndrome. The shunt was originally not visualized on cardiac magnetic resonance imaging but later detected with transesophageal echocardiography. This case highlights the importance of complimentary multimodality cardiac imaging in the diagnosis of both common and uncommon disorders.

Durvalumab-Associated Myocarditis Initially Presenting With Sinus Bradycardia Progressing Into Complete Heart Block.

Durvalumab is a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). It has been recently approved for the treatment of advanced urothelial and non-small cell lung cancer (NSCLC) with a more favorable side effect profile compared to traditional chemotherapy agents. We present a case of durvalumab-induced myocarditis complicated by complete heart block (CHB). A 71-year-old male with a history of atrial flutter status post ablation, type 2 diabetes mellitus, hypertension, and non-small cell lung carcinoma (NSCLC) recently started on durvalumab, presented with new sinus bradycardia on electrocardiogram (EKG). His initial labs were notable for a troponin T of 207 ng/L (normal range ≤50). Transthoracic echo (TTE) and computed tomography angiography (CTA) of the coronaries were unremarkable. The hospital course was complicated by CHB on telemetry for 15 minutes. Given hemodynamic instability, cardiac magnetic resonance imaging (MRI) could not be obtained. The patient received transvenous pacing. Electrophysiology and cardiology-oncology were consulted to evaluate for pacemaker implantation as well as management for durvalumab-induced myocarditis. Methylprednisolone 1000 mg intravenous (IV) was started with an improvement in troponin levels but without improvement in CHB. His course was further complicated by polymorphic ventricular tachycardia prompting the placement of a permanent dual-chamber pacemaker. The patient was discharged on a prednisone taper, and durvalumab was discontinued. A diagnosis of durvalumab-induced myocarditis was made based on elevated troponin levels, with the exclusion of coronary artery disease with CTA of the coronaries. The persistence of conduction abnormalities despite treatment with steroids leads to the placement of a permanent pacemaker. Durvalumab falls under the category of immune checkpoint inhibitor (ICI) therapy which are novel agents that have more favorable side effect profiles compared to traditional chemotherapeutic agents. A review of the literature shows myocarditis with arrhythmias as a potentially rare side effect of ICI therapy. Corticosteroid therapy seems to be promising as a potential therapy.

De novo ulcerative colitis and Takotsubo cardiomyopathy following sleeve gastrectomy.

The increasing prevalence of severe obesity is a major public health concern. Bariatric surgery is an important treatment option for severe obesity due to its long-term sustained result. Multiple studies have shown that patients have an increased risk of developing inflammatory bowel disease following bariatric surgery. Takotsubo syndrome usually presents as acute left ventricular systolic dysfunction without corresponding obstructive coronary artery disease after an acute stress episode. We describe a unique case of a patient who developed de novo ulcerative colitis and takotsubo cardiomyopathy shortly after sleeve gastrectomy. The patient made a successful recovery due to prompt recognition and appropriate treatment.

Dynamic Echocardiographic Imaging of a Valve-in-Valve Mitral Prosthesis.

Dynamic imaging of heart valves and specifically prosthetic valves is a central benefit of echocardiography. Most bioprosthetic heart valves degenerate over a given time and hence require repeat valve replacement which carries a significant risk of morbidity and mortality. Reoperation is the standard of care and may still be required after the first successful surgery due to complications disrupting either mechanical or bioprosthetic valves. Such complications can be delayed or even prevented if optimal prosthesis selection is individualized according to patients' medical and postimplantation follow-up. We present the case of an 84-year-old woman where an open-heart valve-in-valve approach, implanting a mechanical valve in a failed bioprosthetic valve, produced a unique image on transthoracic echocardiography which needs to be recognized by imagers for appropriate patient diagnosis and management.

Intermittent Epicardial Lead Failure Detected Using a Continuous Ambulatory Electrocardiogram Monitor.

A 69-year-old man received epicardial pacing leads for complete atrioventricular block that occurred during a mechanical tricuspid valve replacement procedure. During follow-up, the patient reported intermittent episodes of dizziness and bradycardia. Remote transmissions and device interrogations failed to elucidate the cause of his symptoms. A continuous ambulatory electrocardiogram (ECG) monitor was used as an alternative diagnostic tool. Multiple pauses were detected by the monitor and, upon review, these events were deemed to be due to the intermittent loss of capture by the epicardial lead. Once this diagnosis was made and the malfunctioning lead was replaced, the patient's symptoms resolved. This case highlights the novel use of a continuous ambulatory ECG monitor in diagnosing intermittent loss of capture, which was not detected by remote monitoring or device interrogations.

Sex Differences in Coronary Arterial Calcification in Symptomatic Patients.

Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p < 0.001, 95% CI [2.01, 4.59]) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC > 100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.

Coronary CT Calcium Score in Patients With Prior Nongated CT, Is it Necessary?

PURPOSE: To evaluate the percentage of patients undergoing gated coronary artery calcium score CTs that had a prior nongated chest CT. To assess the accuracy of prior nongated chest CTs in the detection of coronary calcium. BACKGROUND: Cardiovascular disease is the most common cause of death worldwide. Quantifying coronary artery calcification on gated calcium score CT has proven to be strongly predictive of adverse coronary artery disease events. However, visual estimation and ordinal scoring on nongated chest CTs is predictive of coronary calcium burden. METHODS: Consecutive gated calcium score CTs at a single institution from 10/2014 to 10/2016 were retrospectively evaluated with IRB approval/waiver of informed consent. The presence or absence of coronary calcium and ordinal score on nongated chest CT was compared to Agatston score on gated calcium score CT. RESULTS: Forty-two of 441 patients (9.5%) with a gated calcium score had a prior nongated chest CT, with a mean time difference of 810 days. Of the 42 prior chest CTs, 69% had coronary artery calcium (CAC) and 31% did not, with 100% predictive accuracy for the presence or absence of CAC on subsequent gated calcium score CTs. There was 86% correlation of Agatston score on gated calcium score CT with ordinal score on the prior chest CT. Ordinal score divided into independent groups of severity was related to increased severity of Agatston score on the gated calcium score CT (P< 0.001). A majority of prior chest CT studies with coronary calcium failed to include this information in the final report. CONCLUSIONS: A large percentage of gated calcium score CTs were performed despite a prior chest CT. The ordinal score on chest CTs correlated with Agatston score on gated calcium score CTs. The presence of CAC on chest CTs was underreported in a majority of cases.

Proarrhythmic Manifestations of Neuromuscular Dystrophinopathies.

Muscular dystrophy has been an elusive term ever since it was first described in the 19th century. Introduced in 1891 by Wilhelm Heinrich Erb, muscular dystrophy has been classified as part of a larger group of genetically determined, progressive degenerative neuromuscular disorders termed "dystrophinopathies." Cardiac arrhythmias may occur during the neurologic course of the disease. Although descriptions of the dystrophinopathies have been reported in the literature, few articles address the use of antiarrhythmic pharmacotherapy in patients with muscular dystrophy. We discuss the pathophysiology of the most common dystrophinopathies, their proarrhythmic sequelae, and the therapeutic use of antiarrhythmic agents in the clinical setting.

Preoperative nuclear stress testing in the very old patient population.

BACKGROUND: Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population. AIM: To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery. METHODS: Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed. RESULTS: A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P < 0.01) more likely to develop peri-operative MACE. CONCLUSION: Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery.

Aortic Pseudoaneurysm Causing Compression of the Left Main Coronary Artery.

A 75-year-old man with a history of mechanical aortic valve replacement with aortic conduit for severe aortic insufficiency underwent routine screening computed tomography evaluation revealing right coronary anastomosis endoleak and proximal aortic root pseudoaneurysm.