Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management

The prevalence of takotsubo cardiomyopathy (TCM) has been on the rise, but co-occurrence with hypertrophic cardiomyopathy (HOCM) remains rare. Although presenting patient demographics were similar to those in TCM, the potential for hemodynamic compromise was significantly compounded by the presence of underlying HOCM. Management was similar to standalone TCM, although use of inotropic agents and mechanical support appears to be more prevalent. Despite the increased potential for complications and the paucity of data regarding management, outcomes appear to be mostly favorable in both the hospitalization period and at follow-up. Interestingly, despite a new diagnosis of HOCM in about half the cases described, which signifies no significant left ventricular outflow tract (LVOT) gradient prior to TCM, half of those patients had a persistently elevated LVOT gradient after resolution of TCM. This poses a question of whether or not TCM can predispose to LVOT obstruction in HOCM patients even after its resolution

Outcomes of cardiogenic shock with autoimmune rheumatological disorders

Aims: Data on cardiogenic shock (CS) in autoimmune diseases (AID) is limited. Our study aims to evaluate in-hospital outcomes of CS in hospitalized patients with underlying AID compared with patients without AID. Methods: The National Inpatient Sample (NIS) database years 2011-17 was used to identify hospitalizations for CS. We retrospectively compared in-hospital outcomes of CS in patients with underlying AID versus non-AID. Results: Of 863,239 patients diagnosed with CS, 23,127 (2.7%) had underlying AID. The AID population was older with more women and African American patients (P \u3c 0.001 for all). There was a significant increase in in-hospital mortality in patients with AID vs non-AID that persisted after adjustment for demographics, comorbidities, insurance, socioeconomic status and hospital characteristics (38.3% vs 36.3%, aOR 1.06; 95% CI: 1.02-1.09, P = 0.001). Patients with AID had a lower rate of respiratory complications (11.5% vs 13.1%), acute stroke (6.0% vs 6.8%), use of mechanical circulatory support (12.0% vs 14.5%) and discharge to an outside facility (29.1% vs 28.8%) (P ≤ 0.001 for all). Using multivariable logistic regression, we identified female gender, Native American ethnicity, heart failure, coagulopathy, pulmonary circulation disorders, metastatic cancer, and fluid and electrolytes disorders as independent predictors of mortality in patients with AID who were diagnosed with CS. Conclusion: Patients with AID hospitalized with CS have increased mortality which may be related to their underlying disease process and lack of effective disease-directed therapy for CS related to AID. Keywords: Autoimmune Disease; Cardiogenic Shock; Mortality

Ipsilateral Vocal Cord Paralysis After Acute Anterior Ischemic Stroke

Introduction: The vocal cord is innervated by the recurrent laryngeal nerve and the superior laryngeal nerve, which are branches of the vagus nerve. The nucleus ambiguous is a motor nucleus of the vagus nerve and it is located in the medulla. It receives supratentorial upper motor regulatory fibers. Commonly, this regulation is bilaterally represented in the brain. Less commonly, it is contralaterally represented. This case describes a rare presentation. Case presentation: We present a female patient in her early sixties with a past medical history significant for hypertension who presented with acute right-sided weakness and expressive aphasia (National Institutes of Health Stroke Scale = 20). Computed tomography (CT)-head was unremarkable but she was outside the window for chemical thrombolytic therapy. CT-angiogram revealed occlusion of the left extracranial and intracranial internal carotid artery and, thus, she was deemed not a candidate for mechanical thrombectomy. CT-perfusion scans (Rapid software) showed a large penumbra within the respective vascular territory affected including the operculum and the insula. The core infarction was relatively small and located in the left basal ganglia. After inducing therapeutic hypertension, the patient\u27s aphasia improved. Surprisingly, this unmasked a moderate to severe hypophonic voice. The patient underwent flexible fiberoptic laryngoscopy which showed a paralyzed left vocal cord but without signs of inflammation. Conclusion: Our case is a rare case of transient ipsilateral vocal cord paralysis associated with anterior unilateral cerebral ischemia. The paralysis resolved with improvement of the cerebral ischemic penumbra

National Trends of Percutaneous Mechanical Support Utilization During Percutaneous Coronary Interventions in Chronic Total Occlusion

Coronary chronic total occlusion (CTO) is common in patients with multivessel coronary artery disease. Percutaneous coronary artery (PCI) interventions have shown favorable outcomes in patients with CTO. Nevertheless, the data regarding the utilization of mechanical circulatory support in CTO PCIs is not well established. We sought to investigate the trends in utilization and periprocedural complications in this population. Using the National Inpatient Sample database from 2011 to 2019, we identified patients diagnosed with CTO who underwent PCI. We investigated the presence of a linear trend in the utilization of mechanical circulatory support (MCS) during those procedures and the associated periprocedural complications using the Cochran-Armitage method. A total of 208,123 patients who were diagnosed with CTO and underwent PCI from 2011 to 2019, of which in 6,319 patients MCS was used during the procedure. Patients in the MCS group were older (67.4 vs 66.4 years), less likely to be women (24.0% vs 26.4%), and equally likely to be African-American (9.4% vs 8.8%) with a higher burden of co-morbidities in terms of coronary artery disease, congestive heart failure, and atrial fibrillation (p \u3c0.001 for all). Using the Cochrane-Armitage method, we found a statistically significant linear uptrend in the utilization of MCS from 269 (1.4%) to 990 cases (7.0%) from 2011 to 2019. Using multivariable logistic regression, female gender, renal failure, alcohol abuse, coagulopathy, and fluid and electrolyte disorders were identified as independent predictors of mortality in CTO PCI procedures assisted with MCS (p ≤0.007). In conclusion, the utilization of MCS in CTO PCI procedures has been increasing over the years. Female gender and renal failure are independently associated with a higher mortality risk

COVID-19: The Impact on Internal Medicine Resident Training

The novel coronavirus disease 2019 (COVID-19) pandemic has impacted the lives of physicians at all levels. The workloads and working hours have increased tremendously which affected the time spent on administrative and academic duties. The COVID-19 pandemic imposed a lot of challenges on academic institutions in term of providing quality of care to patients and maintaining the quality of education for trainee. Herein, we discuss the challenges and impact of the pandemic on residents training. Keywords: COVID-19; medical education; residency training

The Significance of Contrast Density of the Computed Tomography-Angiographic Spot Sign and its Correlation with Hematoma Expansion

BACKGROUND AND PURPOSE: The computed tomography angiographic (CTA) spot sign has been shown to predict hematoma expansion in patients with intracranial hemorrhage (ICH), but the significance of the spot sign density (SSD) and the spot sign ratio (SSR) has not yet been explored. METHODS: Using the institutional Neurocritical care and Stroke registry, we retrospectively reviewed patients with ICH from January-2013 to June-2017. We selected patients who had baseline CT-head (CTH), CTA with positive-spot sign within 6hours of last known well and at least one follow-up CTH within 24hours. Baseline demographics and variables known to affect hematoma-volume were collected. Hematoma-volumes and SSR were calculated using computer-assisted 3D-volumetric measurement and the average of the surrounding hematoma density divided by the SSD, respectively. The 2-sample t test and the area-under-the-curve (receiver operating characteristic) were used to detect the association between hematoma expansion and outcome at discharge. RESULTS: A total of 320 patients were reviewed; 22 met the inclusion criteria. Significant hematoma expansion (volume expansion ≥12.5 cc or ≥33% compared to baseline) was noted in 14 (64%) subjects. SSD was significantly higher in subjects with hematoma expansion (216 ± 66) than those without (155 ± 52, P = .036). With a cut-off SSD of ≥150 HU, we had sensitivity of 86% and specificity of 75%. For SSR, lower ratios suggested a trend toward hematoma expansion, although it was not statistically significant (P = .12). There was no significant correlation between SSD or SSR and modified ranking scale at discharge and after 3-6 months. CONCLUSION: SSD might be a good predictor of hematoma growth. Although SSR showed a trend toward expansion, results were not statistically significant

Impact of chronic kidney disease on in-hospital outcomes and readmission rate after edge-to-edge transcatheter mitral valve repair

Background: Transcatheter mitral valve repair (TMVR) is a treatment option for patients with 3+ or greater mitral regurgitation who cannot undergo mitral valve surgery. Outcomes in patients with chronic kidney disease (CKD) and end stage renal disease (ESRD) are unclear. We sought to evaluate the TMVR in-hospital outcomes, readmission rates and its impact on kidney function. Methods: Data from 2016 National Readmission Database was used to obtain all patients who underwent TMVR. Patients were classified by their CKD status: no CKD, CKD, or ESRD. The primary outcomes were: in-hospital mortality, 30- and 90-day readmission rate, and change in CKD status on readmission. Multivariable logistic regression analysis was used to assess in-hospital, readmission outcomes and kidney function stage. Results: A total of 4,645 patients were assessed (mean age 78.5 ± 10.3 years). In-hospital mortality was higher in patients with CKD (4.0%, odds ratio [OR]:2.01 [95% CI, confidence interval: 1.27-3.18]) and ESRD (6.6%, OR: 6.38 [95% CI: 1.49-27.36]) compared with non-CKD (2.4%). 30-day readmission rate was higher in ESRD versus non-CKD patients (17.8% vs. 10.4%, OR: 2.24 [95% CI: 1.30-3.87]) as was 90-day readmission (41.2% vs. 21% OR: 2.51 [95% CI:1.70-3.72]). Kidney function improved in 25% of patients with CKD stage 3 and in 50% with CKD stage 4-5 at 30-and 90-day readmission. Incidence of AKI, major bleeding, and respiratory failure were higher in CKD group. Conclusions: Patients with CKD and ESRD have worse outcomes and higher readmission rate after TMVR. In patients who were readmitted after TMVR, renal function improved in some patients, suggesting that TMVR could potentially improve CKD stage. Keywords: MitraClip; chronic kidney disease; end stage renal disease; transcatheter mitral valve repair

Role of Magnetic Resonance Imaging in Diagnosis of Motor Neuron Disease: Literature Review and Two Case Illustrations

Motor neuron diseases (MNDs) are a group of devastating neurologic disorders that cause specific damage to the motor neuron cells. The current diagnosis of MND is based on results of the clinical examination and neurophysiologic studies. The length of time of referral to a neuromuscular neurologist and the lack of validated diagnostic criteria can delay diagnosis. Although the role of imaging is currently most useful in excluding other conditions, several attempts to incorporate neuroimaging in the diagnosis of the disease and assessment of progression have shown promising results.We conducted a literature review via searches in PubMed and The Cochrane Database using multiple relevant terms to the topic. Two cases with a challenging diagnosis of MND are described, with a thorough discussion of how the diagnosis was suggested on the basis of magnetic resonance imaging evidence in each case. Advanced magnetic resonance imaging findings can be useful tools that add to the diagnostic criteria of MNDs, especially in cases where reaching a definitive diagnosis is difficult. Such findings might enable clinicians to reach an early diagnosis that can improve the patient\u27s quality of life and prolong survival

Echocardiographic Derived Parameters Association with Long Term Outcomes After Transcatheter Valve Replacement

BACKGROUND: Transaortic flow, maximum velocity (V max), mean gradient (MG), left ventricular ejection fraction (LVEF), Aortic valve area (AVA) and dimensional index (DI) are important determinants of prognosis in patients with severe aortic stenosis. The specific role of these echocardiography-derived values in predicting prognosis of severe aortic stenosis patients undergoing Transcatheter aortic valve replacement (TAVR) is less defined. METHODS: We identified all severe AS patients who underwent TAVR between 01/2012 and 6/2016. Baseline characteristics, clinical, procedural and one year follow-up data were obtained. Hierarchical logistic regression was used to assess predictors of 1-year mortality after TAVR. Normal flow (NF) was defined as having stroke volume index (SVI) of ≥35 ml/m2; while low Flow (LF) was defined as SVI \u3c 35 ml/m2. High gradient (HG) was defined as mean gradient of ≥40 mmHg; while low gradient (LG) was defined as \u3c40 mmHg. RESULTS: A total of 399 patients were analyzed. There were no significant differences in baseline characteristics. LVEF less than 35% was associated with higher rate of 1-year mortality (17.6% LVEF \u3c35% vs. 8.9% LVEF≥35%; RR = 2.19; CI 1.05 to 4.54; P = 0.03). There was no difference in 1-year mortality outcomes after TAVR in relation to: Mean Gradient MG, transaortic flow/Stroke Volume Index SVI, DI, V max or AVA. CONCLUSION: Low LVEF \u3c35% remains the strongest parameter associated with 1 year mortality after TAVR

Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke

Introduction: Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don\u27t improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning. Methods: Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6). Results: Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, \u3c0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved. Conclusion: Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies. Keywords: Admission-NIHSS; Discharge-NIHSS; Mildly symptomatic LVO stroke; Minor-LVO stroke; Non-perfusion