Outcomes of Octogenarian Patients Treated with Tafamidis for Transthyretin Amyloid Cardiomyopathy.

Patients with transthyretin amyloid cardiomyopathy (ATTR-CM) benefit from disease-modifying agents such as tafamidis. However, the survival benefit of tafamidis in elderly patients (age ≥80 years) is not reported. This study aimed to assess the survival of patients with ATTR-CM aged 80 years and older who were treated with tafamidis compared with patients aged <80 years. We conducted a retrospective analysis of patients with ATTR-CM who underwent tafamidis treatment, aged 45 to 97 years at the time of diagnosis between January 1, 2008, and May 31, 2021. A total of 484 patients were included, with 208 in the ≥80 years group and 276 in the <80 years group. The cohort was followed up for mortality outcomes, and hazard ratios with 95% confidence intervals were calculated. After a median follow-up of 18.5 months, 72 deaths were recorded in the entire cohort. Kaplan-Meier curves showed no differences in survival probability between the 2 groups at 30 months (p for log-rank test = 0.76). The survival rates for patients aged ≥80 years who underwent treatment at 1, 2, 3, 4, and 5 years were 94.7%, 86.0%, 77.0%, 77.0%, and 38.5%, respectively. The corresponding rates for patients aged <80 years who underwent treatment were 93.2, 84.8, 74.4, 68.2, and 64.6%, respectively. In the multivariable analysis, the hazard ratio (95% confidence interval) of the mortality comparing treatment patients aged ≥80 years with those aged <80 years was 0.81 (0.41 to 1.61). In conclusion, tafamidis treatment is associated with similar reductions in mortality in older and younger patients with ATTR-CM.

Contemporary applications of multimodality imaging in infective endocarditis.

INTRODUCTION: Infective endocarditis (IE) is an increasingly important condition with significant morbidity and mortality. With advancements in cardiovascular interventions including prosthetic valve implantation and utilization of intracardiac devices, the prevalence of IE is rising in the modern era. Early detection and management of this condition are critical. AREAS COVERED: This review presents a contemporary review of the applications of multi-modality imaging in IE, taking a comparative approach of the various imaging modalities. EXPERT OPINION: Transthoracic and transesophageal echocardiography are essential imaging modalities in establishing the diagnosis of IE, as well as evaluating for complications of IE. Other imaging modalities such as cardiac computed tomography and nuclear imaging play an important role as adjuvant imaging modalities for the evaluation of IE, particularly in prosthetic valve IE and cardiovascular implantable device associated IE. It is crucial to understand the strengths, weaknesses, and clinical application of each imaging modality, to improve the diagnosis, management, and outcomes of patients with IE.

Contemporary Trends in Clinical Characteristics, Therapeutic Strategies and Outcomes in Patients Aged 80 Years and Older Presenting with non-ST Elevation Myocardial Infarctions in the United States.

The current guidelines for the management and treatment of acute coronary syndromes do not fully consider the role of age in guiding medical or invasive management. We investigated the characteristics, management strategies, and clinical outcomes of patients aged 80 years and older presenting with non-ST elevation myocardial infarction (NSTEMI). A cohort study using the nationwide inpatient sample database of patients aged 80 years and older presenting with NSTEMI in the United States between 2012 to 2018 was performed. About 24.2% (151,472/625,916) of NSTEMI patients were 80 years and older. Older patients (≥80 years) had higher in-hospital mortality and cardiovascular complications compared to younger patients (odds ratio (OR) 1.79, 95% confidence intervals (CI) 1.71-1.88, P < 0.001). Among older patients, conservative medical management was associated with higher inpatient mortality compared to percutaneous coronary intervention (PCI) (OR 2.3, 95% CI 2.18-2.41, P < 0.001) or coronary artery bypass graft (CABG) (OR 1.9, 95% CI 1.76-2.09, P < 0.001). The highest mortality rate was observed in older patients who underwent both PCI and CABG, followed by those treated conservatively and those undergoing coronary angiography without revascularization. This study provides valuable insights into the clinical characteristics and outcomes of elderly patients presenting with NSTEMI in the United States. The results emphasize the importance of a tailored approach to the management of ACS in elderly patients and the need for improved revascularization strategies to reduce in-hospital mortality and adverse cardiovascular outcomes. Therefore, the clinician should tailor the management of older patients presenting with NSTEMI.

Challenges in diagnosis and therapeutic options for metastatic prostate cancer to the right ventricle.

Our patient presented with right-sided heart failure symptoms and found to have a large mass protruding into the heart's right ventricle. Cardiac MRI delineated the morphological and tissue characteristics of the tumour. Although 18-fluorodeoxyglucose positron emission tomography (PET) did not reveal an intracardiac mass, the lesion was well demonstrated by Fluciclovine F18 PET/CT.

Utility of Intracardiac Echocardiography for Infective Endocarditis and Cardiovascular Device-Related Endocarditis: A Contemporary Systematic Review.

The diagnosis of infective endocarditis (IE) can pose a significant challenge, particularly in cases of prosthetic valve endocarditis (PVE) or cardiac device-related endocarditis (CDIE) (1). While echocardiography remains a crucial diagnostic tool for identifying IE, including PVE and CDIE, there are certain circumstances where transesophageal echocardiography (TEE) may not be conclusive or practically feasible (2). Recently, intracardiac echocardiography (ICE) has emerged as a promising alternative for diagnosing IE and evaluating intracardiac infections, especially in cases where transthoracic echocardiography (TTE) has not been revealing, and TEE has been contraindicated. Furthermore, ICE has been found to be useful in guiding transvenous lead extractions in infected implantable cardiac devices (3). This systematic review aims to comprehensively explore the various applications of ICE in the diagnosis of IE and assess its efficacy in comparison to traditional diagnostic methods.

Trends and Outcomes of Left Atrial Appendage Occlusion in Renal and Liver Transplant Recipients: Insights From the United States National Inpatient and Readmission Database.

Left atrial appendage occlusion using the Watchman device has emerged as an alternative treatment strategy for preventing strokes in patients with atrial fibrillation. However, there is no data on its safety and clinical outcomes in prior renal or liver transplant recipients. We included a total of 61,995 patients from the National Inpatient Sample (NIS, in-hospital outcomes) and 55,048 patients from the National Readmission Database (NRD, 30-day outcomes) who underwent percutaneous left atrial appendage occlusion (LAAO). From this group, 0.65% (n=405) and 0.62% (n=339) were renal and liver transplant recipients in NIS and NRD respectively. Transplant recipients were younger compared with non-transplant recipients (mean age 69 vs 77 years, P=<0.01). There was little difference in terms of in-hospital mortality (0% vs 0.2%, P=0.43), major complications (6.2% vs 5.6%, P=0.61), cardiovascular complications (2.5% vs 2.8%, P=0.73), neurological complications (1.2% vs 0.7%, P=0.21) or bleeding complications (1.2% vs 0.7%, P=0.99) between transplant vs. non-transplant patients. Based on the NRD database, 30-day readmission rate was not meaningfully different for transplant recipients undergoing LAAO (9.44%) when compared to non-transplant patients (8.12%, [log-rank, P=0.56]). There was no difference between 30-day major or cardiovascular complications, however vascular complication rates were significantly higher for transplant recipients (OR 2.56, 95% CI [(1.66-3.47]). Our study findings suggest that LAAO may be safe for patients with a prior renal or liver transplant in terms of major complications, cardiovascular complications, and all-cause readmission rates. However vascular complications may be higher in transplant recipients. Further large-scale studies are needed to confirm these findings.

Advanced Cardiovascular Imaging for the Diagnosis of Mycobacterium chimaera Prosthetic Valve Infective Endocarditis After Open-heart Surgery: A Contemporary Systematic Review.

Mycobacterium chimaera is an opportunistic and emerging pathogen, which has been recognized to cause prosthetic valve infective endocarditis and disseminated infection following open-chest cardiac surgery with certain contaminated heater-cooler systems. Diagnostic evaluation of suspected prosthetic valve infective endocarditis due to M chimaera is challenging and requires a very high index of suspicion. This systematic review aims to evaluate prosthetic valve infective endocarditis due to M chimaera. Based on the current literature review, transesophageal echocardiography and 18F-fluorodeoxyglucose positron emission tomography/computed tomography are the most common imaging modalities used to establish the diagnosis. Based on 22 published cases, the reported cases of M chimaera endocarditis have occurred almost entirely in males. Within this cohort, the patients developed endocarditis on average 2.7 years after exposure to contaminated heater-cooler systems during cardiac surgery. M chimaera infection is associated with significant morbidity and mortality.

Trends, Predictors, and Outcomes of 30-Day Readmission With Heart Failure After Transcatheter Aortic Valve Replacement: Insights From the US Nationwide Readmission Database.

BACKGROUND Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established. METHODS AND RESULTS The Nationwide Readmission Database was used to identify 30-day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all-cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30-day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30-day readmission rate for HF did not show a significant decline during the study period (Ptrend=0.06); however, all-cause readmission rates decreased significantly (Ptrend=0.03). HF readmissions were comparable between high- and low-volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end-stage renal disease were independent predictors of 30-day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non-HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non-HF readmission. CONCLUSIONS During the study period from 2015 to 2018, 30-day HF readmissions after TAVR remained steady despite all-cause readmissions decreasing significantly. All-cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low-, medium-, and high-volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non-HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR.

When cardiology meets endocrinology: sustained atrial flutter associated with thyrotoxic periodic paralysis.

Periodic paralysis is a rare muscle disease that manifests as episodes of painless muscle weakness, and the hypokalemic form is commonly associated with hyperthyroidism. Most tachyarrhythmias related with thyrotoxicosis include sinus tachycardia and atrial fibrillation, but an association between thyrotoxic hypokalemic periodic paralysis and typical atrial flutter has seldomly been documented. Here, we present the case of a young male who was diagnosed with thyrotoxic periodic paralysis causing cavotricuspid isthmus-dependent atrial flutter, successfully treated with diltiazem, propranolol, methimazole, potassium iodine (SSK) and rivaroxaban.

In-hospital outcomes of transapical versus surgical aortic valve replacement: from the U.S. national inpatient sample.

OBJECTIVE: To compare the outcomes of transapical transcatheter aortic valve replacement (TA-TAVR) and surgical aortic valve replacement (SAVR) using a large US population sample. METHODS: The U.S. National Inpatient Sample was queried for all patients who underwent TA-TAVR or SAVR during the years 2016-2017. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were in-hospital stroke, pericardiocentesis, pacemaker insertion, mechanical ventilation, vascular complications, major bleeding, acute kidney injury, length of stay, and cost of hospitalization. Outcomes were modeled using multi-variable logistic regression for binary outcomes and generalized linear models for continuous outcomes. RESULTS: A total of 1560 TA-TAVR and 44,280 SAVR patients were included. Patients who underwent TA-TAVR were older and frailer. Compared to SAVR, TA-TAVR correlated with a higher mortality (4.5% vs. 2.7%, effect size (SMD) = 0.1) and higher periprocedural complications. Following multivariable analysis, both TA-TAVR and SAVR had a similar adjusted risk for in-hospital mortality. TA-TAVR correlated with lower odds of bleeding with (adjusted OR (aOR) = 0.26; 95% CI: 0.18-0.38;P < 0.001), and a shorter length of stay (adjusted mean ratio (aMR) = 0.77; 95% CI: 0.69-0.84; P < 0.001), but higher cost (aMR = 1.18; 95% CI: 1.10-1.28; P < 0.001). No significant differences in other study outcomes. In subgroup analysis, TA-TAVR in patients with chronic lung disease had higher odds for mortality (aOR = 3.11; 95%CI: 1.37-7.08; P = 0.007). CONCLUSION: The risk-adjusted analysis showed that TA-TAVR has no advantage over SAVR except for patients with chronic lung disease where TA-TAVR has higher mortality.

Unusual presentation of pulmonary blastomycosis complicated by amphotericin-induced refractory electrolyte abnormalities.

Blastomyces dermatitidis is an endemic mold infection commonly seen in the midwestern of the USA and rarely affects pregnant women. The most common presentation is a pulmonary infection with variable degrees of severity. Of note, the clinical and radiographic findings of pulmonary blastomycosis can be mistaken for other pulmonary pathologies, thus earning the title of 'the great pretender'. The treatment of choice of infected pregnant patients is amphotericin B, which is known to produce electrolyte imbalances. However, it infrequently causes severe, prolonged and profound hypokalemia and hypomagnesemia. We present the case of a 27-year-old pregnant patient with pulmonary blastomycosis presenting with a lung mass suspicious of malignancy and treated with amphotericin B with subsequent prolonged refractory hypokalemia and hypomagnesemia. Keywords pulmonary blastomycosis pregnancy biopsy computed tomography angiography liposomal amphotericin B.

Primary cutaneous B-cell lymphoma-leg type in a young adult with HIV: a case report.

Primary cutaneous B-cell lymphoma is a very rare entity. Skin lesions mainly occur on the lower extremities. Sheets of immunoblasts and centroblasts are characteristic findings at histologic examination. This case report highlights diagnostic and therapeutic strategies for primary cutaneous B-Cell lymphoma-leg type.

Critical Care Management for Novel 2019 SARS-CoV-2 and HCoV-NL63 Coinfection in a Young Immunocompromised Patient: A Chicago Experience.

BACKGROUND: SARS-CoV-2 is a newly emerged virus that has spread rapidly, exhibiting tremendous morbidity and mortality. Some potential pharmaceutical targets have been identified but are still lacking proper validation. Case Presentation. We describe the case of a young, immunosuppressed and critically ill patient with previous Influenza B infection, requiring extracorporeal membrane oxygenation, which was then followed, in the succeeding months, by SARS-CoV-2 infection complicated by severe adult respiratory distress syndrome. Her clinical course exhibited complications, including pulmonary embolism, acute kidney injury, pneumothorax, pneumomediastinum, multiple cardiac arrests, and eventually death. CONCLUSION: Coinfection with other respiratory pathogens and opportunistic infections are possible.

Diagnosis of Infective Endocarditis by Subtype Using 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Contemporary Meta-Analysis.

Background Infective endocarditis (IE) remains a difficult to diagnose condition associated with high mortality. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has recently emerged as another IE imaging modality, although diagnostic accuracy varies across observational studies and types of IE. This meta-analysis assessed the diagnostic performance of 18F-FDG PET/CT for IE and its subtypes. Methods We searched Pubmed, Cochrane, and Embase from January 1980 to September 2019 for studies reporting both sensitivity and specificity of 18F-FDG PET/CT for IE. Meta-Disc 1.4 was used to pool data for all cases of IE and its subgroups of native valve IE, prosthetic valve IE, and cardiac implantable electronic devices IE. Results We screened 2566 records from the search, assessed 52 full-text articles, and included 26 studies totaling 1358 patients (509 IE cases). Pooled sensitivity and specificity (95% CI, inconsistency I-square statistic) were 0.74 (0.70-0.77, 71.5%) and 0.88 (0.86-0.91, 78.5%) for all cases of endocarditis. Corresponding parameters for native valve IE were sensitivity 0.31 (0.21-0.41, 29.4%) and specificity 0.98 (0.95-0.99, 34.4%); for prosthetic valve IE: sensitivity 0.86 (0.81-0.89, 60.0%) and specificity 0.84 (0.79-0.88, 75.2%); and for cardiac implantable electronic devices IE: sensitivity 0.72 (0.61-0.81, 76.2%) and specificity 0.83 (0.75-0.89, 83.6%). Pooled sensitivities and specificities were higher for the 17 studies since 2015 than the 9 studies published before 2015. Conclusions 18F-FDG PET/CT had high specificity for all IE subtypes; however, sensitivity was markedly lower for native valve IE than prosthetic valve IE and cardiac implantable electronic devices IE. It is, therefore, a useful adjunct modality for assessing endocarditis, especially in the challenging scenarios of prosthetic valve IE and cardiac implantable electronic devices IE, with improving performance over time, related to advances in 18F-FDG PET/CT techniques.

A Recovered Case of COVID-19 Myocarditis and ARDS Treated With Corticosteroids, Tocilizumab, and Experimental AT-001.

We describes a case of a critically ill patient with myocarditis and severe acute respiratory distress syndrome related to coronavirus disease-2019. This case highlights management strategies, including the use of corticosteroids, an interleukin-6 inhibitor, and an aldose reductase inhibitor, resulting in complete clinical recovery. (Level of Difficulty: Intermediate.).

Unexpected Reduced Biventricular Ejection Fraction in a Healthy Young Male.

We describe the case of a 31-year-old male who came to the emergency department complaining of marked bilateral lower extremities edema, dyspnea, fatigue, and exertion intolerance. Strategies for the management of viral myocarditis with acute heart failure include pharmacological therapies and mechanical circulatory assist devices if required. Despite multiple available diagnostic methods and treatments, viral myocarditis remains as an etiology of challenging diagnosis, and poor prognosis with a high mortality rate.

Bicuspid Aortic Valve Associated with Severe Aortic Regurgitation and Large Aortic Root Aneurysm.

We described the case of a 30-year-old male who came to the Emergency Department complaining of left shoulder pain and dyspnea under exertion. A bicuspid aortic valve and aneurysm of root and ascending aorta were diagnosed. These were initially managed with medical therapy and ultimately with definitive surgical correction.

Erdheim-Chester Disease With Extensive Pericardial Involvement: A Case Report and Systematic Review.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis characterized by systemic xanthogranulomatous infiltration. We described the case of a female adult presenting with pericardial effusion. Pericardial infiltration is the most frequent cardiac manifestation of ECD and is the one discussed in this article. We found that the majority of patients with pericardial infiltration needed a cardiovascular procedure.

Carcinoid Right Heart Disease.

Carcinoid heart disease is an unusual cause of right heart failure. We present the case of a 53-year-old man with a history of metastatic carcinoid tumors originating from the appendix, status post-chemotherapy, and liver embolizations. The patient presented with a right-sided valvular disease with severe pulmonic valve regurgitation, right ventricle dilation and pulmonary hypertension. He had carcinoid syndrome well controlled with long-acting lanreotide. He underwent tricuspid valve and pulmonary valve replacement with a stented bioprosthetic valve, maze and cardio-septal right ventricular outflow tract patch with an improvement of ventricular dysfunction. These findings supported the diagnosis of carcinoid heart disease presenting with pure right heart failure. The patient was symptom-free due to lanreotide, but ultimately, valve surgery is the preferred definite treatment in suitable patients. Carcinoid heart disease requires a high index of suspicion, and valve surgery is the only definitive treatment.