Blastocyst or Blastomycosis?: A Rare Presentation of Disseminated Blastomycosis With Cardiac Involvement in Pregnancy.

Disseminated blastomycosis with cardiac manifestations is exceedingly rare. Here we present the first known case of disseminated, cardiac blastomycosis in a pregnant patient. Antifungal medications and a multidisciplinary, nonsurgical approach were successful in eradicating the fungal cardiac mass and in preventing vertical transmission to the fetus. (Level of Difficulty: Advanced.).

Low voltage-guided ablation of posterior wall improves 5-year arrhythmia-free survival in persistent atrial fibrillation.

INTRODUCTION: The posterior wall (PW) has been proposed as a standard target for ablation beyond pulmonary vein antral isolation (PVI) in patients with persistent atrial fibrillation (AF). However, studies have shown inconsistent outcomes with the addition of PW ablation. The presence or absence of low voltage on the PW may explain these inconsistencies. We evaluated whether PW ablation based on the presence or absence of low voltage improves long-term arrhythmia-free outcomes. METHODS: We retrospectively reviewed 5-year follow-up in 152 consecutive patients who received either standard ablation (SA) with PVI alone or PVI + PW ablation (PWA) based on physician discretion (n = 77) or voltage-guided ablation (VGA) with PVI and addition of PWA only if low voltage was present on the PW (n = 75). RESULTS: The two groups were well matched for baseline characteristics. At 5-year follow-up, 64% of patients receiving VGA were atrial tachyarrhythmia (AT)/AF free compared to 34% receiving SA (HR 0.358 p < .005). PWA had similar AF recurrence in SA and VGA groups (0.30 vs. 0.27 p = .96) but higher AT recurrence when comparing SA and VGA groups (0.39 vs. 0.15 p = .03). In multivariate analysis, both VGA and PWA predicted AF arrhythmia-free survival (HR 0.33, p = .001 and HR 0.20, p = .008, respectively). For AT, VGA predicted arrhythmia-free survival (HR 0.22, p = .028), while PWA predicted AT recurrence (HR 4.704, p = .0219). CONCLUSION: VGA of the posterior wall ablation beyond PVI in persistent AF significantly improves long-term arrhythmia-free survival when compared with non-voltage-guided ablation. PW ablation without voltage-guidance reduced AF recurrence but at the cost of a higher incidence of AT.

Postoperative Myocardial Injury in Patients Classified as Low Risk Preoperatively Is Associated With a Particularly Increased Risk of Long-Term Mortality After Noncardiac Surgery.

Background Prior studies have shown an association between myocardial injury after noncardiac surgery (MINS) and all-cause mortality in patients following noncardiac surgery. However, the association between preoperative risk assessments, Revised Cardiac Risk Index and American College of Surgeons National Surgical Quality Improvement Program, and postoperative troponin elevations and long-term mortality is unknown. Methods and Results A retrospective chart review identified 548 patients who had a troponin I level drawn within 14 days of noncardiac surgery that required an overnight hospital stay. Patients aged 40 to 80 years with at least 2 cardiovascular risk factors were included, while those with trauma, pulmonary embolism, and neurosurgery were excluded. Kaplan-Meier survival and odds ratio (OR) with sensitivity/specificity analysis were performed to assess the association between preoperative risk and postoperative troponin elevation and all-cause mortality at 1 year. Overall, 69%/31% were classified as low-risk/high-risk per the Revised Cardiac Risk Index and 66%/34% per American College of Surgeons National Surgical Quality Improvement Program. Comparing the low-risk versus high-risk groups, preoperative risk assessment was not associated with either postoperative troponin elevation or 1-year mortality. MINS portended a 1-year mortality of OR, 3.9 (95% CI, 2.44-6.33) in the total population. Patients classified as low risk preoperatively with MINS had the highest risk of 1-year mortality (OR, 9.6; 95% CI, 4.27-24.38), with a low prevalence of statin use. Conclusions Current preoperative risk stratification tools do not prognosticate the risk of postoperative troponin elevation and all-cause mortality at 1 year. Interestingly, patients classified as low risk preoperatively with MINS had a markedly higher 1-year mortality risk compared with the general population, and most of them are not taking a statin. Our results suggest that evaluating preoperatively low-risk patients for MINS presents an opportunity for prognostication, risk reclassification, and initiating therapies such as statins to mitigate long-term risk.