One year follow up for case series of myocarditis following mRNA vaccination against SARS-CoV-2.

In 2021, the first rounds of modified mRNA vaccines against SARS-CoV-2 were tested and deployed. The vaccines themselves had great efficacy against severe infection, with rare and minimal side effects. One adverse effect that was reported, however, was incidence of myocarditis seen amongst mostly young males after their second vaccination dose. The disease course was self-limited. This study group published a case series in August of 2021 of four cases of this phenomenon. This paper is a followup to the original case series, providing an updated literature review and expert recommendations concerning the safety and benefits of the vaccines.

Echocardiographic characteristics of patients with antisynthetase syndrome.

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) occurs in approximately one-third of patients with interstitial lung disease (ILD) and is associated with reduced 6-minute walk distance (6MWD), and increased hospitalizations and mortality. Although the impact of RV dysfunction and PH has been well described in several types of ILD, data is scarce on antisynthetase syndrome. Therefore, we sought to examine the presence of RV dysfunction and PH in patients with antisynthetase syndrome and the impact on clinical outcomes. We conducted a retrospective study of patients with antisynthetase syndrome. Seventy-five subjects were identified. Fifty-one (68%) subjects had echocardiographic data. Patients were grouped into those with normal fractional area change (FAC) ≥ 35% and reduced FAC < 35%. Clinical, echocardiographic, and right heart catheterization data were compared between the two groups. Subjects with FAC < 35% had lower diffusion capacity of the lung for carbon monoxide (29% vs. 47%, p = 0.004), fibrotic features on computed tomography of the chest (79% vs. 33%, p = 0.005), larger RV diameter (5.4 vs. 3.9 cm, p < 0.001), higher right atrial pressures (8 vs. 5 mmHg, p = 0.02), and required supplemental oxygen more frequently (100% vs. 44%, p < 0.001) compared to those with FAC ≥ 35%. We found no difference in 6MWD and hospitalizations between the two groups. The presence of RV dysfunction in antisynthetase syndrome may identify patients at risk of poor outcomes.

Massive Tension Hemothorax After Pacemaker Implantation.

A case of an 85-year-old male on apixaban and clopidogrel undergoing pacemaker implantation is described. After procedure he developed unilateral tension hemothorax and required emergent drainage and exploratory thoracotomy. No vascular, cardiac, or pulmonary source was identified. After multidisciplinary discussions, it was speculated that spontaneous intercostal vessel rupture due to forceful coughing and elevated blood pressure during the procedure was the most likely cause of bleeding.

Myocarditis following mRNA vaccination against SARS-CoV-2, a case series.

INTRODUCTION: mRNA COVID-19 vaccines have emerged as a new form of vaccination that has proven to be highly safe and effective against COVID-19 vaccination. Rare adverse events including myocarditis have been reported in the literature. METHODS: Data were gathered from the electronic medical record of four patients personally treated by the authors. RESULTS: Four patients, ages 20 to 30, presented with myocarditis characterized by chest pain, elevations in troponin-I and C-reactive protein, and negative viral serologies two to four days following mRNA vaccine administration. One had a cardiac MRI showing delayed gadolinium enhancement in a subpericardial pattern. All experienced symptom resolution by the following day, and the two who have returned for follow-up had normal troponin-I and CRP values. DISCUSSION: Along with previously reported instances, these cases raise suspicion for a possible link between mRNA vaccines and myocarditis.

Acute Myocardial Infarction in a Young Woman: Role of Cardiac Magnetic Resonance Imaging in Establishing the Diagnosis.

Evaluation of acute coronary syndromes (ACS) in young women presents a clinical challenge. An unremarkable coronary angiogram may not exclude ACS, as spontaneous lesion revascularization, resolved coronary spams, or spontaneous coronary dissection (SCAD) can often be missed. Cardiac magnetic resonance imaging (CMR) can provide useful information in acute myocardial infarction (MI) by confirming and sizing acute infarction and delineating the etiology when angiography is inconclusive. Here, we report a case of a 39-year-old postpartum woman with a history of hyperlipidemia who presented with a one-day history of atypical angina. On presentation, she was found to have transient ST-segment elevation in high lateral leads and elevated troponin. Coronary angiography revealed a nonobstructive lesion in the first obtuse marginal branch (OM1) distribution. The patient subsequently underwent cardiac magnetic resonance imaging (MRI) for further delineation of etiology, which confirmed acute infarction in the OM1 distribution. Diagnosis of myocardial infarction with no obstructive coronary artery disease (MINOCA) secondary to acute coronary artery dissection type 2 (SCAD-2) was made. The patient was managed conservatively with medical therapy. CMR has emerged as a front-line diagnostic imaging modality in acute MI and can provide invaluable information in the confirmation and sizing of infarction, delineating tissue characteristics, establishing the etiology of infarction, and prognostication.

Impact of pretransplant mitral annular calcification on the incidence of cardiac events after renal transplantation.

BACKGROUND: Mitral annular calcification (MAC) is associated with increased risk of major adverse cardiac events. We hypothesized that MAC, identified on a pretransplant transthoracic echocardiography (TTE), is predictive of cardiac events following renal transplantation (RT). METHODS: In a retrospective cohort of consecutive RT recipients, pretransplant MAC presence and severity were determined on TTE performed within 1 year prior to transplant. MAC severity was quantified based on the circumferential MAC extension relative to the mitral valve annulus. Post-transplant cardiac risk was assessed using the sum of risk factors (range: 0-8) set forth by the American Heart Association/American College of Cardiology Foundation consensus statement on the assessment of RT candidates. Subjects underwent pretransplant stress single-photon emission computed tomography myocardial perfusion imaging and followed for post-transplant composite outcome of cardiac death or myocardial infarction (CD/MI). RESULTS: Among 336 subjects (60.5% men; mean age 52 ± 12 years), MAC was present in 78 (23%) patients. During a mean follow-up of 3.1 ± 1.9 years, a total of 70 events were observed. Patients with MAC had a higher event rate compared with those without MAC (34.6% versus 17.8%, log-rank P = 0.001). There was a stepwise increase in CD/MI risk with increasing MAC severity (P for trend = 0.002). MAC-associated risk remained significant after adjusting for sex, duration of dialysis, sum of risk factors, ejection fraction and perfusion abnormality burden, providing an incremental prognostic value to these parameters (Δχ2 =4.63; P = 0.031). CONCLUSION: Among RT recipients, the burden of pretransplant MAC is an independent predictor of post-transplant risk of CD/MI. MAC should be considered in the preoperative assessment of RT candidates.

Prosthetic Mitral Valve Obstruction with Left Atrial Appendage Thrombus: A Therapeutic Dilemma.

Valvular obstruction is a rare but life-threatening complication of mechanical prosthetic valves that raises significant challenges in management. We describe a unique case of mechanical mitral valve obstruction with co-existing left atrial appendage (LAA) thrombus. A 48-year-old man with a past medical history of atrial fibrillation and mechanical mitral valve replacement 18 months prior, presented with symptoms of new onset heart failure for 10 days. INR on presentation was sub-therapeutic. Trans-thoracic and trans-esophageal echocardiography revealed prosthetic mitral valve obstruction with mobile, echogenic masses seen on the mechanical valve as well as LAA, suggestive of thrombus. His clinical course rapidly deteriorated and he developed cardiogenic shock. He was deemed to have prohibitive risk for emergent surgical intervention. He received trial of thrombolytic therapy, with partial improvement of hemodynamic parameters and a mild decrease in thrombus burden. He then underwent surgical intervention with a favorable outcome. Intra-operative visualization of the prosthetic valve revealed a combination of pannus and thrombus. Prosthetic valve function should be promptly assessed in patients presenting with heart failure symptoms, as clinical deterioration can be rapid. Acute presentation, history of inadequate anticoagulation and appearance of soft mass on an echocardiogram, are suggestive of thrombus as the etiology of valve obstruction. However, thrombus and pannus are known to frequently co-exist. Emergent surgery is the recommended management strategy in patients with left-sided prosthetic valve thrombosis with the New York Heart Association (NYHA) III or IV symptoms, due to a lower rate of thrombo-embolism, major bleeding, and recurrent prosthetic valve thrombosis when compared with thrombolytic therapy. Slow-infusion, low-dose thrombolytics were recently shown to have favorable outcomes and can be considered when surgery is not available or the patient is deemed to have prohibitive surgical risk.

Incidence and predictors of late atrioventricular conduction recovery among patients requiring permanent pacemaker for complete heart block after cardiac surgery.

BACKGROUND: New-onset complete heart block (CHB) commonly complicates cardiac surgery, for which some patients require a permanent pacemaker (PPM). Little is known regarding late atrioventricular (AV) conduction recovery. OBJECTIVE: The purpose of this study was to characterize the incidence and predictors of late AV conduction recovery among patients requiring PPM after cardiac surgery. METHODS: Consecutive patients receiving PPM for CHB after cardiac surgery at a high-volume U.S. center from 2000 to 2014 were evaluated. The primary outcome was late AV conduction recovery, defined as a reduction in ventricular pacing requirement to <10% beyond 1 month postimplant. Regression analysis was performed to evaluate predictors of AV recovery. RESULTS: Among 301 patients evaluated over 4 ± 4 years of follow-up, the incidence of late AV conduction recovery was 12% (n = 37), for whom the median ventricular pacing requirement decreased from 96% at implant to <1% at 6 months and persisted throughout study follow-up. AV recovery was less common when preoperative conduction abnormalities were present, including no recovery among patients with preoperative PR >200 ms and QRS >120 ms (n = 42). Multivariable analysis identified only female sex and transient AV conduction postoperatively as independent predictors of recovery (odds ratio 3.5; P <.01 for each). Neither cardiac surgery subtype nor PPM implant timing postoperatively was significantly associated with recovery. CONCLUSION: Late AV conduction recovery is not uncommon after cardiac surgery, occurring in 1 of 8 patients within 6 months postoperatively. Preoperative AV conduction abnormalities were associated with decreased recovery, whereas female sex and transient postoperative AV conduction were associated with increased recovery.

C-GRApH: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management. METHODS AND RESULTS: Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C-GRApH). The C-GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre-OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, P<0.001) in the development cohort and 0.81 (0.76-0.87, P<0.001) in the validation cohort. When subdivided by C-GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) C-GRApH scores in the development and validation cohorts, respectively. CONCLUSIONS: C-GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C-GRApH ≤1) and poor (C-GRApH ≥4) prognoses.

Utility of hand-held devices in diagnosis and triage of cardiovascular emergencies. Observations during implementation of a PACS-based system in an acute aortic syndrome (AAS) network.

BACKGROUND: Prompt diagnosis and early referral to specialized centers is critical for patients presenting with cardiovascular emergencies, including acute aortic syndromes (AAS). Prior data has suggested that mobile access to imaging studies with hand-held devices can accelerate diagnosis and management. OBJECTIVE: We conducted a study to determine the diagnostic accuracy of a hand-held device compared to conventional dedicated work-stations for diagnosing a spectrum of cardiovascular emergencies, predominantly acute aortic pathology. METHODS: This study included 104 cases who underwent computed tomography (CT)-scan during "on-call'' hours between January, 2013 and August, 2014 for suspected AAS. Assessment was performed on a hand-held device independently by two readers using an iPhone5 connected via secure connection to web-based PACS servers. The subsequent interpretation from a dedicated workstation coupled with the diagnosis at the time of discharge was used as the reference standard for determining the presence or absence of an acute abnormality. Sensitivity and Specificity were calculated on a per patient basis. RESULTS: Readers' sensitivity and specificity using the hand-held device to diagnose acute chest pathology were calculated. Hand-held device evaluation was determined to have a sensitivity of 85.2% and a specificity of 98.6% by reader A and a sensitivity of 96.3% and specificity of 100% by reader B. Of 103 cases interpreted by both readers, the readers agreed about the diagnosis in 98 cases (95.1%). CONCLUSION: This study demonstrates that hand-held devices can be a potential useful tool to assist in diagnosis and triage of patients presenting with cardiovascular emergencies. Further studies are needed to assess the impact of screen size and resolution.