FOLFOX Induced Takotsubo Cardiomyopathy Treated with Impella Assist Device

Chemotherapy induced cardiotoxicity is becoming increasingly prevalent with several new agents being used recently. The incidence of Takotsubo cardiomyopathy due to 5-fluorouracil based chemotherapeutic regimens like FOLFOX is not uncommon. It is also seen with platinum based chemotherapy. Most of these patients have reversible cardiotoxicity and the cardiac function recovers within a short period with supportive treatment. Here we have a patient who presented with cardiogenic shock after 5 days of receiving FOLFOX regimen for colorectal adenocarcinoma. She was treated with a percutaneous left ventricular assist device, Impella CP, for hemodynamic support with excellent outcome

A hazardous finding of a rare anomalous left main coronary artery in a patient with a secundum atrial septal defect

A 23-year-old male referred for evaluation of a “choking” sensation with exertion and a murmur. A transthoracic echocardiogram demonstrated right atrial and ventricular dilatation, right ventricular volume overload, and a large secundum atrial septal defect (ASD) with left to right shunt and a calculated pulmonary-to-systemic blood flow ratio (Qp/Qs) estimated at 2.3 to 1. Cardiac catheterization also demonstrated evidence of the ASD with Qp/Qs of 4.6 to 1 with a significant step-up in oxygen saturation at the right atrial level. Additionally, an anomalous left main coronary artery (ALMCA) origin from the anterior right coronary cusp was suspected. Using 64-slice multidetector computed tomography coronary angiography (CCTA) the left main coronary artery was seen to arise from the right coronary cusp then traverse between the pulmonary trunk and the proximal ascending aorta before bifurcating into the left anterior descending and circumflex arteries that followed their normal courses distally. Based on the high risk nature of associated sudden death from an anomalous left main coronary artery (ALMCA) coursing between the aorta and the pulmonary trunk, the patient underwent surgical re-implantation of the ALMCA to the left coronary cusp and repair of the ASD. This case highlights a rare finding of a hazardous ALMCA in a patient with a secundum ASD and the utility of CCTA in evaluating the course of coronary anomalies along with other cardiac pathology

Safety and feasibility of dopamine-atropine stress echocardiography

Background Dobutamine-atropine stress echocardiography (DSE) has lower sensitivity in patients with advanced liver disease (ALD) due to vasodilation. Hypothesis Dopamine-atropine stress echocardiography (DopSE) may be an alternative to DSE in ALD patients by improving the blood pressure response to stress. Methods The safety and tolerability of DSE and DopSE were compared in 10 volunteers. The safety, adverse effects, and efficacy of DopSE were then assessed in 105 patients, 98 of whom had ALD. Dopamine was infused in stepwise fashion from 5 µg/kg/min to a peak dose of 40 µg/kg/min. Atropine was given before and in early stages of dopamine infusion up to cumulative dose of 1.5 mg. The hemodynamic responses of 98 ALD patients were compared with 102 patients with ALD who underwent standard DSE. Results In normal volunteers, systolic BP increased more with DopSE compared to DSE (61 ± 19 mm Hg vs 39 ± 15 mm Hg, P = .008). In 105 patients who underwent DopSE, none had adverse effects that required early stress termination. In the groups with ALD, the systolic BP increase (38 ± 28 mm Hg vs 12 ± 27 mm Hg, P < .001) and peak rate pressure product (RPP) (22 861 ± 5289 vs 17 211 ± 3848, P = <.001) were both higher in those undergoing DopSE versus DSE. The sensitivity and specificity of DopSE were 45% and 88%, respectively for coronary disease (≥70% stenosis) in 37 patients who had angiography. Conclusions Dopamine-atropine stress echocardiography appears to be a safe stress modality and provides greater increases in RPP in patients with ALD compared to DSE

National Estimates for the Percentage of All Readmissions with Demographic Features, Morbidity, Overall and Gender-Specific Mortality of Transcutaneous Versus Open Surgical Tricuspid Valve Replacement/Repair

BACKGROUND: The aim of the study was to determine national estimates for the percentage of all readmissions with demographic features, length of stay (LOS), cost analysis, comorbidities, complications, overall and gender-specific mortality and complications of transcutaneous tricuspid valve replacement/repair (TTVR) vs. open surgical tricuspid valve replacement/repair (open TVR). METHODS: Data were extrapolated from the Nationwide Readmissions Database (NRD) 2015-19. Of the 75,266,750 (unweighted) cases recorded in the 2015 - 2019 dataset, 429 had one or more of the percutaneous approach codes as per the ICD-10 dataset, and 10,077 had one or more of the open approach codes. RESULTS: Overall, the number of cases performed each year through open TVR was higher than TTVR, but there was an increased trend towards the TTVR every passing year. TTVR was performed more in females and advanced age groups than open TVR. The LOS and cost were lower in the TTVR group than in open TVR. Patients undergoing TTVR had more underlying comorbidities like congestive heart failure, hypertension, and uncomplicated diabetes mellitus. Overall mortality was 3.49% in TTVR vs. 6.09% in open TVR. The gender-specific analysis demonstrated higher female mortality in the open TVR compared to TTVR (5.45% vs. 3.03%). Male mortality was statistically insignificant between the two groups (6.8% vs. 4.3%, P-value = 0.15). Patients with TTVR had lower rates of complications than open TVR, except for arrhythmias, which were higher in TTVR. Patients undergoing open TVR required more intracardiac support, such as intra-aortic balloon pump (IABP) and Impella, than TTVR. CONCLUSION: TTVR is an emerging alternative to open TVR in patients with tricuspid valve diseases, especially tricuspid regurgitation. Despite having more underlying comorbidities, the TTVR group had lower in-hospital mortality, hospital cost, LOS, and fewer complications than open TVR

Validation of the Internet Addiction Test in Students at a Pakistani Medical and Dental School

Despite growing concerns over pathological internet usage, studies based on validated psychometric instruments are still lacking in Pakistan. This study aimed to examine the psychometric properties of the Internet Addiction Test (IAT) in a sample of Pakistani students. A total of 522 students of medicine and dentistry completed the questionnaire, which consisted of four sections: (a) demographics, (b) number of hours spent on the Internet per day, (c) English version of the IAT, and (d) the Defense Style Questionnaire-40. Maximum likelihood analysis and principal axis factoring were used to validate the factor structure of the IAT. Convergent and criterion validity were assessed by correlating IAT scores with number of hours spent online and defense styles. Exploratory and confirmatory factor analysis reflected the goodness of fit of a unidimensional structure of the IAT, with a high alpha coefficient. The IAT had good face and convergent validity and no floor and ceiling effects, and was judged easy to read by participants

Electromagnetic Interference between Subcutaneous ICD and HeartMate II LVAD

ICDs have been shown to have a significant benefit in reducing sudden cardiac death in patients with systolic heart failure. Additionally, cardiac devices as a bridge to transplant or destination therapy are often used in patients with end stage systolic heart failure. As a result most patients with LVADs also have an ICD. Subcutaneous ICD(S-ICD) was recently introduced into clinical trials to defibrillate ventricular arrhythmias, avoiding drawbacks of transvenous leads. It is therefore not surprising to find complexities arising such as this case of inappropriate S-ICD shock due to electromagnetic interference (EMI) between HeartMate II LVAD and S-ICD. A 31-year-old woman with a history of postpartum cardiomyopathy (American College of Cardiology stage D) was seen in the advanced heart Failure clinic with complaint of multiple S-ICD shocks over the last few months. The patient reported an implantation of a Boston Scientific S-ICD 7 months and a St. Jude HeartMate II LVAD as destination therapy 4 months prior to the presentation. S-ICD interrogation revealed multiple inappropriate shocks secondary to EMI between the two devices. Since the patient had no documented ventricular arrhythmias or history of ICD therapy prior to LVAD placement, it was decided to turn off the S-ICD and consider a transvenous ICD in the future if she should develop any significant arrhythmias. EMI created by LVADs in the presence of an ICD has been previously described but to our knowledge this is the first case reporting EMI between HeartMate II and S-ICD. Multiple different methods have been described to resolve EMI between LVAD and transvenous ICD including “Pseudo” Faraday Cage and “Pan” methods. In cases of non-compatible devices, implantation of the transveous ICD in the contralateral side of LVAD has been also tried successfully, however it is unclear if repositioning the S-ICD pulse generator or the lead can change the vector adequately to avoid EMI. Additionally S-ICDs do not have the ability to engage in anti-tachycardia pacing to prevent shocks which are potentially lethal negative nootropic events in patients with severe LV dysfunction. Consequently, some patients may need transvenous ICD implantation to potentially resolve these issues. As cardiac devices continue to evolve, it is critical for advanced heart failure/ transplant cardiologists and electrophysiologists to understand potential interactions, and make appropriate pre-operative choices to eliminate this potential issue. Image 1: Close proximity of LVAD and S-ICD in our patient which potentially can increase the risk of EMI

FOLFOX Induced Takotsubo Cardiomyopathy Treated with Impella Assist Device

Chemotherapy induced cardiotoxicity is becoming increasingly prevalent with several new agents being used recently. The incidence of Takotsubo cardiomyopathy due to 5-fluorouracil based chemotherapeutic regimens like FOLFOX is not uncommon. It is also seen with platinum based chemotherapy. Most of these patients have reversible cardiotoxicity and the cardiac function recovers within a short period with supportive treatment. Here we have a patient who presented with cardiogenic shock after 5 days of receiving FOLFOX regimen for colorectal adenocarcinoma. She was treated with a percutaneous left ventricular assist device, Impella CP, for hemodynamic support with excellent outcome

Acute-Onset Heart Failure Secondary to Biventricular Non-Compaction Cardiomyopathy and Atrial Septal Defect in a Woman Presenting in the Seventh Decade

We present a case of a previously asymptomatic 63-year-old woman who presented with worsening dyspnoea for 3 weeks. Initial transthoracic and later transoesophageal echocardiography confirmed biventricular non-compaction cardiomyopathy and a large secundum atrial septal defect (ASD) measuring 1.4 cm. Additionally, there was a haemodynamically significant left to right shunt causing acute decompensated systolic heart failure. She eventually underwent closure of the septal defect using a AMPLATZER Septal Occluder device. Decision to close the defect was made as the left to right shunt was causing severe pulmonary hypertension and acute heart failure. Since most heart failure treatments involve lowering of the LV afterload there was consideration that this could cause right to left shunting and could cause an Eisenmenger physiology. Hence the AMPLATZER Septal Occluder device was placed to eliminate the shunt through the ASD. The ASD combined with the non-compaction posed significant treatment challenge in this case