Catastrophic Cardiac Complications of Takayasu\u27s Arteritis.

Takayasu\u27s arteritis (TA) causes inflammation and necrosis of vessel walls, leading to aneurysm formation, extensive coronary damage and valvular abnormalities. We review a case of recurrent coronary, aortic and mitral valve involvement in a patient with TA and discuss the various treatment options available for such patients

Coronary Artery Aneurysm Presenting as Non-ST Elevation Myocardial Infarction.

Coronary artery aneurysms are rare in the general population. There are no randomized control trials to guide the therapy at this moment. We present a case of a 52-year-old male who was recovering from addiction and was sober for past five years. He came to the hospital with typical chest pain. There were ST segment depressions in leads III and AVF. The second troponin was found to be elevated. The impression was non-ST-segment elevation myocardial infarction. He was started on subcutaneous enoxaparin and underwent left heart catheterization which revealed dilated ectatic coronary arteries with aneurysmal dilatation. In addition, there was sluggish blood flow and several blood clots mainly in the left circumflex artery. No intervention was performed and the patient was started on heparin drip which was transitioned to warfarin on discharge. The echocardiogram revealed an ejection fraction of 35% with anterior and inferoseptal wall dyskinesia. Echocardiogram at one-year follow-up showed improved ejection fraction of 50% with similar wall dyskinesia. Coronary artery aneurysms are treated with medical management with or without invasive approach. Invasive management is conducted in people with stenosis and can be achieved by coronary artery bypass graft or covered stents

Pacemaker Placement in Persistent Left Superior Vena Cava.

Persistent left superior vena cava (PLSVC) is a rare disorder which is asymptomatic and hence is usually discovered while performing interventions through the left subclavian vein. We present a case of a 78-year-old male who was undergoing elective placement of a permanent pacemaker for tachycardia - bradycardia syndrome with post-conversion pauses of up to nine seconds. After achieving access through the left subclavian vein the wire kept on going on the left side of the chest instead of crossing the midline to the right side. The wire was removed and contrast venography was done, PLSVC with dilated coronary sinus emptying into the right atrium was confirmed. There was some difficulty in passing the lead to the right ventricle even with the acute curve in the stylet. The sheath size was increased and a longer deflectable sheath was used and with the tip of the lead anteriorly the right ventricle was cannulated and the lead was affixed. There were good sensing and pacing parameters. Post procedure chest x-ray was done and the patient was discharged without any complications

EOSINO-FEEL-YA HEART BEAT FAST: A CASE OF VENTRICULAR TACHYCARDIA DUE TO EOSINOPHILIC MYOCARDITIS

Background: Eosinophilic myocarditis (EM) is a rare form of myocardial inflammation characterized by a predominantly eosinophilic infiltrate. The clinical presentation can vary, but EM is often fatal with a high in hospital mortality. Case: A 63 year old Caucasian male with a history of angioimmunoblastic T- cell lymphoma and subsequent hypereosinophilic syndrome (HES) presented with sudden onset of lightheadedness. The patient was found to be in pulsatile monomorphic sustained ventricular tachycardia (VT). He underwent cardioversion and initiation of amiodarone therapy. Labs demonstrated peripheral hypereosinophilia of 32% and pancytopenia. Cardiac MRI demonstrated a large area of organized fibrotic thrombus in the right and left ventricular (LV) apex consistent with his clinical HES along with a preserved LV ejection fraction. Decision-making: Amiodarone was initiated immediately and load commenced during his hospital stay. Glucocorticoids are the initial therapy of choice in this clinical scenario and they were promptly initiated. The strategy of defibrillator implantation in the setting of sustained ventricular arrhythmia due to myocarditis is not routine. Due to the possibility of cardiac fibrotic recovery with therapy and his pancytopenia, it was recommended that the patient undergo prolonged steroid therapy, oncology guided chemotherapy, with reassessment of his endomyocardium in 4-6 weeks. Guided by the observational registry of the AVID trial and the European guidelines, he was discharged with a LifeVest for secondary prevention. He also left on amiodarone along with therapeutic enoxaparin. Conclusion: This case demonstrates a clinical presentation of HES and the myocardial complications of thrombus formation, fibrosis and subsequent VT. It also illustrates the utility of a LifeVest in patients with transient conditions for which recovery is possible

DURABILITY OF LEFT BUNDLE BRANCH AREA PACING.

BACKGROUND: Left bundle branch area pacing (LBBAP) is a form of conduction system pacing. Long term data on the safety and performance of LBBAP one year post device implantation has not been well described. METHODS AND RESULTS: Sixty-five patients (49% females) who received LBBAP for bradycardia indications using the SelectSecure 3830 lead (Medtronic, Minneapolis, MN) were retrospectively evaluated. Clinical variables were examined. Lead parameters were obtained at implant and during regular follow-up. Mean age of patients was 75.7±10.1 years with left ventricular ejection fraction 59.8±10.4%. Indications for pacing were atrioventricular block 55%, sinus node dysfunction 19%, tachy-brady syndrome 15%, atrioventricular node ablation 8%, and bail out CRT 3%. Mean baseline QRS measured 120±38ms, paced QRS duration was 138±22ms. Paced QRS narrowed by 24ms in those with preexisting left bundle branch block (BBB), increased by 1ms in those with preexisting right BBB, and increased by 42ms in those with no BBB. LBBAP threshold at implant was 0.521±0.153V @0.4ms, and increased to 0.654±0.186V at 3 months (+26%), 0.707±0.186 V at 6 months (+36%), and 0.772±0.220V at 12 months (+48%). Patients with left BBB showed the maximum benefit with QRS narrowing 24ms. Pacing impedance remained unchanged with no procedure related complications. CONCLUSION: LBBAP is a durable form of conduction system pacing with pacing thresholds remaining relatively stable over 12 months post device implantation. Patients with left BBB display the narrowest paced QRS. This article is protected by copyright. All rights reserved

New Model of Automated Patient-Reported Outcomes Applied in Atrial Fibrillation.

Background The value of patient-reported outcomes (PRO) is increasingly recognized in patient-centered care. Longitudinal data collection may be challenging and cost prohibitive. Automation of PRO collection may complement routine clinical follow-up, especially for procedures aiming to improve quality of life, such as atrial fibrillation (AF) ablation. Methods We aimed to develop a fully automated platform to collect PRO and evaluate its first clinical application in a prospective cohort of AF ablation. The duration of follow-up and data availability were assessed with automated PRO and routine follow-up versus routine follow-up alone (primary outcome). Quality of life and healthcare utilization (secondary outcomes) by PRO were assessed. Results Between 2013 and 2016, 2175 patients were eligible to receive 10 903 PRO assessment invitations, and the automated platform sent all invitations as programmed. More follow-up assessments were obtained with automated PRO and routine follow-up compared with routine follow-up alone (12 859 versus 10 248;