Post-myocardial Infarction Left Ventricular Aneurysm With Contained Rupture and Hemopericardium.

Left ventricular aneurysms (LVAs) represent a rare yet critical complication arising from late-presenting myocardial infarction (MI). Here, we present the case of an 88-year-old male with chest pressure, elevated troponin, B-type natriuretic peptide, and lactate. The electrocardiogram showed sinus tachycardia and an old right bundle branch block. The patient was started on heparin infusion, but progressively worsening hypotension necessitated transfer to the intensive care unit and the initiation of vasopressors. The echocardiogram identified a focal aneurysm in the mid-anterolateral wall, moderate pericardial effusion with a coagulum, and tamponade physiology. Computed tomography angiography of the chest confirmed a moderate pericardial effusion with density consistent with hemopericardium. LVAs pose a substantial threat of cardiovascular morbidity and mortality. While echocardiography serves as the initial assessment method, supplemental imaging modalities may need to be utilized. Various complications have been reported with LVA, including thromboembolization, ventricular arrhythmias, pericardial effusion with tamponade, and left ventricular rupture which accounts for 5%-24% of all in-hospital deaths related to MI. Although LVAs are the most common mechanical complications following an MI, instances of contained aneurysm rupture leading to hemopericardium are infrequent and scarcely reported. High clinical suspicion and prompt imaging with echocardiography are essential for diagnosis. Determining the optimal timing and selection between surgical and percutaneous interventions necessitates additional research for informed decision-making.

Pacing-Induced Cardiomyopathy in Leadless and Traditional Pacemakers: A Single-Center Retrospective Analysis.

BACKGROUND:  Pacing-induced cardiomyopathy (PICM) is a clinical syndrome that is characterized by a drop in the left ventricular ejection fraction (LVEF) due to chronic high-burden right ventricular (RV) pacing. It has been postulated that leadless pacemakers (LPs) cause decreased risk of PICM compared to transvenous pacemakers (TVPs), but the exact risk reduction is unknown. METHODS: We performed a single-center retrospective analysis of adults who received an LP or TVP between January 1, 2014, and April 1, 2022, and had echocardiograms before and after the pacemaker implant. This study's outcomes were the RV pacing percentage, change in EF, the need for cardiac resynchronization therapy (CRT) upgrade, and follow-up duration. A Wilcoxon rank-sum test calculated the change in EF. RV time, defined as the duration from pacemaker placement to the follow-up echocardiogram in months multiplied by the RV pacing percentage, served as a surrogate for how long the RV was paced. RESULTS: A total of 614 patients were screened, and 198 patients were included in the study, where 72 received LP and 126 received TVP. The median follow-up was 480 days. The average of the reported RV percentage pacing was 63.43% for LP and 71.30% for TVP (p=0.14). The incidence of PICM and CRT upgrade was 44% and 9.7% in the LP group and 37% and 9.5% in the TVP group (p=0.3 and p>0.9), respectively. After accounting for age, sex, LP versus TVP, atrioventricular nodal ablation, RV pacing percentage, and follow-up duration, univariate analysis showed that RV time was significantly different between the two types of pacemakers (13.54 ± 14.21 months (LP) versus 9.26 ± 13.95 months (TVP), p=0.009). The difference in RV time between patients who underwent CRT upgrade and those who did not was statistically insignificant (12.11 ± 14.47 months (no CRT) versus 9.19 ± 12.00 months (CRT), p=0.5). CONCLUSIONS: This analysis demonstrated that the incidence of PICM was high in both groups (44% (LP) versus 37% (TVP)), despite significantly more RV time in patients with LP. There was no difference in CRT upgrade between LP and TVP.

Pulmonary Artery Denervation as a New Therapeutic Option for Pulmonary Hypertension: A Systematic Review and Meta-Analysis.

Pulmonary hypertension (PH) is a progressive disease with a high morbidity and mortality. The treatment is based on the type of PH. Prognosis still remains poor despite the use of different medications. Pulmonary artery denervation (PADN) has been studied as a novel therapeutic option in these patients. PUBMED, EMBASE and COCHRANE databases were searched by 2 investigators until January 2023. Information was analyzed for the following outcomes: 6-minute walk distance (6MWD), mean pulmonary artery pressure, pulmonary vascular resistance and cardiac output. Subgroup analysis comparing pre and post PADN in different PH groups was done. Statistical analysis was performed with the Review Manager version 5.4. This meta- analysis included 6 controlled trials and 6 single-arm prospective studies with a total of 616 patients. Our pooled analysis showed a significant reduction in mean pulmonary artery pressure [WMD -6.51, 95% CI (-9.87, -3.15), p = 0.0001], pulmonary vascular resistance [WMD -3.69, 95% CI (-6.74, -0.64), p = 0.02] and increased cardiac output [WMD -0.37, 95% CI (0.08, 0.65), p = 0.01]. Subgroup analysis pre and post PADN demonstrated a significant improvement in 6MWD in the WHO group 1 [WMD 99.53, 95% CI (19.60, 179.47), p = 0.01], group 2 [WMD: 69.96, 95% CI (36.40, 103.51), p = < 0.0001] and group 4 [WMD: 99.54, 95% CI (21.80, 177.28), p = 0.01]. This meta-analysis supports PADN as a therapeutic option for patients with PH, regardless of group class. Further randomized trials are still needed to evaluate safety and efficacy.

Uncommon Cause of Internal Mammary Artery Pseudoaneurysm.

Background: Internal mammary artery pseudoaneurysms most commonly develop from thoracic penetrating trauma or procedures. However, other important etiologies should not be overlooked. Case Report: A 27-year-old female presented with antiphospholipid antibody syndrome, thrombotic microangiopathy, end-stage renal disease on hemodialysis, and epilepsy. On admission, the patient had pulseless electrical activity and hypertensive emergency. After the patient was successfully resuscitated, she developed status epilepticus. Laboratory workup on admission revealed a subtherapeutic international normalized ratio, elevated C-reactive protein and sedimentation rate, and acute anemia. Imaging showed a right-sided subdural hematoma with a midline shift and likely internal mammary artery pseudoaneurysm. Angiography demonstrated aneurysmal dilation, segmental narrowing, and a string of beads appearance. Because of our patient's demographics, string of beads appearance on diagnostic angiography, history of renal disease, and negative hepatitis serology, fibromuscular dysplasia was considered the etiology of the internal mammary artery pseudoaneurysm. The family opted for 2 burr holes and a subdural drain but declined further diagnostic and therapeutic interventions because of anoxic brain injury and poor prognosis. Conclusion: In this patient, the etiology of the internal mammary artery pseudoaneurysm was attributed to fibromuscular dysplasia. Although this patient's family chose comfort measures, treatment methods are available for internal mammary artery pseudoaneurysms.

Efficacy and Safety of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis.

Due to a high risk of recurrent thromboembolism in patients with antiphospholipid syndrome (APS), long-term anticoagulation is recommended. For decades, vitamin K antagonists (VKAs) have been the gold standard for thromboprophylaxis in these patients. Due to the widespread use of direct oral anticoagulants (DOACs) in various thromboembolic conditions and their potential advantages compared to VKAs, several studies have been conducted to evaluate their safety and efficacy in APS. We performed a literature search using PubMed, Embase, and Cochrane databases for studies comparing DOACs to VKAs in patients with APS. Relative risk (RR) and the corresponding 95% confidence intervals (95% CI) were estimated for recurrent thromboembolic events, bleeding, and mortality. A total of 1437 patients pooled from 12 studies were analyzed. The risk of recurrent thrombosis, especially arterial thrombosis, doubled with DOACs compared to VKAs (RR 2.61, 95% CI 1.44-4.71; p=0.001). The risk further increased in patients with a triple-positive antiphospholipid antibody profile (RR 4.50, 95% CI 1.91-10.63; p=0.0006) and with the use of rivaroxaban (RR 1.95, 95% CI 1.10-3.45; p=0.02). The risk of major bleeding and mortality were not significantly different between the two arms. A trend favoring DOACs compared to VKAs was observed for all bleeding events.  This meta-analysis comes in agreement with previous studies and supports the use of VKAs in APS. Our study revealed that VKAs remain the gold standard for the management of APS, especially triple-positive APS. DOACs, particularly rivaroxaban, are not as effective in preventing recurrent thromboembolism in high-risk APS patients. Further studies are needed to evaluate the role of DOACs apart from rivaroxaban with a focus on their efficacy in the management of isolated or double-positive APS.

Meta-Analysis Comparing Distal Radial Artery Approach Versus Traditional for Coronary Procedures.

Distal radial artery access (DRA) is recommended as the preferred approach over the traditional proximal radial artery access (TRA) for coronary procedures; however, there are limited randomized controlled trials (RCTs) that compared the 2. We conducted an updated meta-analysis of all RCTs from inception to July 26, 2021, that compared DRA versus TRA in patients who underwent coronary procedures. The statistical analysis was performed using a random effect model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). A total of 5 RCTs were included with a total of 1,005 patients. A pooled analysis of the data showed that the rate of successful cannulation was similar between the 2 arms (RR 0.85, 95% CI 0.68 to 1.07, p = 0.16, I2 = 94%). The rate of radial artery spasm significantly favored the DRA arm as compared with TRA (RR 0.51, 95% CI 0.34 to 0.75, p = 0.0007, I2 = 0%). Significantly more patients from the DRA arm required alternative arterial access. Moreover, the DRA group had an insignificantly decreased rates of radial artery occlusion (RR 0.24, 95% CI 0.05 to 1.20, p = 0.08, I2 = 46%) and early discharge after transradial stenting of coronary arteries access-site hematomas (RR 0.52, 95% CI 0.18 to 1.149, p = 0.22, I2 = 0%). The mean time for hemostasis was significantly shorter in the DRA arm (mean difference -6.64, 95% CI -10.37 to -2.90, p = 0.0005, I2 = 88%). In conclusion, DRA should be considered as a viable, effective, and safe arterial access method for patients who underwent coronary procedures.

Effect of Immunosuppressive Diseases and Rituximab Infusions on Allowing COVID-19 Infection to Relapse.

INTRODUCTION: Relapsing COVID-19 infections have been reported, but their etiology and severity are still unknown. In addition, there have been no cases in the literature that associate relapsing infection with immunosuppression, either from a disease course or medications. CASE PRESENTATION: This case series illustrates two patients who developed a relapsed infection, likely from recent rituximab infusions. In addition, both cases depicted a severe form of infection than the initial one. Laboratory investigations revealed these patients were unable to produce COVID-19 antibodies, even though one of the patients received convalescent plasma. CONCLUSION: Clinicians should be aware of the possibility of relapsing COVID-19, especially in immunosuppressed patients. Because rituximab induces B-cell depletion, it can also decrease the effectiveness of the COVID-19 vaccine. Therefore, these patients should receive the vaccine before their scheduled rituximab infusion.

Rare Cardiac Papillary Fibroelastoma: Right Atrial, Non-Valvular, Large, Symptomatic With Pulmonary Embolism.

INTRODUCTION: Primary cardiac tumors are rarely seen in the general population and only a subset are classified as cardiac papillary fibroelastoma. CASE PRESENTATION: A 59-year-old female that presented for unresponsiveness and cardiac arrest required 4 rounds of cardiopulmonary resuscitation and intubation. Laboratory investigations showed uncompensated respiratory acidosis, hyperkalemia, and elevated troponins. A chest computed tomography angiogram illustrated an acute right pulmonary embolism and a right atrial filling defect. Furthermore, an echocardiogram demonstrated a normal ejection fraction and a large, pedunculated, mobile, and non-valvular echodensity that was attached to the right atrium endocardium. Therefore, the patient was started on a heparin infusion and catheter-directed thrombolysis; however, the mass persisted. A surgical excision was performed, and a 40 mm was removed. The patient was diagnosed with a papillary fibroelastoma based on the clinical symptoms, imaging, and histological findings. CONCLUSION: This patient's papillary fibroelastoma had multiple rare features including right atrial origin, large size, non-valvular location, and developed symptoms. Although this disease can be initially fatal, the patients typically have a favorable prognosis after a successful excision.