Heart Disease in Pregnancy: A Special Look at Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a disorder in which heart failure develops in the last month of pregnancy or within the first five months postpartum. The exact etiology is not known although recent studies suggest angiogenic imbalance is a key factor with soluble fms-like tyrosine kinase-1 (sFlt1) and a cleaved form of prolactin possibly playing important roles. This review discusses the epidemiology, risk factors, diagnosis, treatment and prognosis of PPCM and highlights recent advances in our understanding of this disorder

Recurrent Direct Current Cardioversion Induced Takotsubo Cardiomyopathy. A Case Report and Literature Review

Stress cardiomyopathy (SCM), also called broken heart syndrome and Takotsubo cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and or mid segments of the left ventricle that mimics myocardial infarction, in the absence of obstructive coronary artery disease. Typically patients present within a few hours of exposure to physical or emotional stress. However, the mechanism by which these stressors result in myocardial dysfunction is unclear. Proposed factors include catecholamine excess and coronary vasospasm1. We present the case of a 61-year-old female who experienced acute pulmonary edema secondary to stress cardiomyopathy, on two occasions immediately after undergoing elective direct current cardioversion (DCCV) for atrial fibrillation (Afib). After an urgent hospitalization for management of acute left ventricular failure, she made a complete clinical and echocardiographic recovery. The incidence, clinical implications and prognosis of DCCV induced SCM is unknown. Given DCCV for Afib is a common outpatient procedure and DCCV induced SCM can lead to acute clinical deterioration it is important that physicians are vigilant about this newly recognized DCCV complication

Graves Induced Reversible LVOT Obstruction

We report the case of a 59 year old male with a structurally normal heart who developed symptomatic LVOT obstruction in the setting of Graves disease. His symptoms and LVOT gradient completely resolved once his thyroid function normalized with appropriate treatment. To our knowledge this is the first case report of hyperthyroidism induced reversible LVOT obstruction

A Complicated Case of Triple Valve Infective Endocarditis in an IV Drug User with a Bicuspid Aortic Valve Requiring Three Separate Salvage Operations: A Case Report and Literature Review

Infective endocarditis (IE) is an infection of the endocardium that involves valves and adjacent mural endocardium or a septal defect. Local complications include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal. Diagnosing IE can be straightforward in patients with the typical oslerian manifestations such as bacteremia, evidence of active valvulitis, peripheral emboli, and immunologic vascular phenomena. In the acute course, however, the classic peripheral stigmata may be few or absent, particularly among intravenous drug abuse (IVDA) patients in whom IE is often due to a S. aureus infection of right-sided heart valves. We present a complicated case of a very aggressive native aortic valve MSSA (methicillin sensitive Staphylococcus aureus) IE in a young adult male with a past medical history of bicuspid aortic valve and IV drug abuse. His clinical course was complicated by aortic valve destruction and development of third-degree AV block, as well as an aorto-left atrial fistula requiring emergent operation for AV replacement and patch repair. The patient required two reoperations for recurrent endocarditis and its complications

Anticoagulation Bridging In Patients With Heartmate3 Left Ventricular Assist Device: A Regional Analysis Of The Momentum 3 Trial

Introduction: Advances in left ventricular assist device (LVAD) technologies have led to a significant improvement in pump hemocompatibility. Due to concerns of thromboembolic complications in older generation LVADs, bridging was commonly performed in patients with subtherapeutic INRs. The effects of this strategy on new generation devices are unclear. We analyzed management strategies of subtherapeutic INRs and their effect on outcomes in a subset of patients enrolled in MOMENTUM 3 trial (CAP and IDE). Methods: All patients enrolled in the MOMENTUM 3 trial (CAP and IDE) across 6 centers were screened for inclusion. Patients were included if they underwent implantation of an HMIII device and had a subtherapeutic INR following discharge from their admission for LVAD implant. All episodes of subtherapeutic INR underwent manual chart review to evaluate management strategies taken by clinicians. Strategies were divided into two groups, bridging (with parenteral or intravenous agents) or non-bridging (consisting of adjustments or no change in coumadin dosing). The primary outcome was a composite of death, rehospitalization, CVA, and bleeding events. Results: Of the 225 patients included in the analysis there were total of 235 subtherapeutic INR events. Fifty-six (23.8%) of these INR\u27s were treated with bridging (n= 30 with parenteral agents, n=26 with IV agents) and 179 patients that were not bridged (n=100 coumadin dose adjustment, n=79 no change in coumadin dose). There was no difference in the composite outcome of patients that were bridged compared to those that were not. Conclusion: Subtherapeutic INR is a common event in patients with HM3 LVAD. The management strategy of subtherapeutic INR varies. Management strategy had no effect on mortality, rehospitalization, CVA, or bleeding events

Clinician Approach To Subtherapeutic INR Management In Patients With A Heartmate 3 LVAD: A Regional Subgroup Analysis Of The Momentum 3 (CAP And IDE) Trials

Introduction: Patients with Heartmate 3 LVADs are recommended to be on therapeutic anticoagulation consisting of aspirin and warfarin (with a goal INR of 2-3). No specific recommendations exist for the management of subtherapeutic INRs, leading to a variation in management. This study was performed to evaluate clinician behavior in the management of subtherapeutic INRs. Methods: We performed a regional subgroup analysis of the MOMENTUM 3 (CAP and IDE) Trials including 6 centers in the Mid-America Region. All patients implanted with a HeartMate 3 device and discharged alive were included in the analysis. Patients with subtherapeutic INRs (INR \u3c 2) occurring after the index admission underwent manual chart review to determine the management strategies taken by clinicians. Management strategies were separated into three groups: no action taken, isolated adjustment of coumadin, or bridging with IV (heparin, bivalirudin) or parenteral agents (enoxaparin). Results: Among 225 patients included in the analysis, 130 (58%) patients had a total of 235 subtherapeutic INR events. Management strategy was associated with INR (p\u3c0.001; Figure 1). The most common management strategy was a change in coumadin dose (n=100, 42.5%), which occurred at a median (interquartile range [IQR]) INR of 1.70 (1.50-1.80). This was followed by no change in management (n=79, 33.6%), which occurred at a median (IQR) INR of 1.83 (1.60-1.90). Bridging events occurred the least frequently (n=56, 23.8%) at a median (IQR) INR of 1.50 (1.30-1.64). Conclusion: There was a direct relationship between INR and the management strategies of subtherapeutic INRs. At INRs closest to 2, less invasive strategies such as coumadin adjustments or no change were preferred, while bridging strategies (including enoxaparin, heparin, and bivalirudin) were used at lower INRs. The effect of bridging strategies on clinical outcomes including mortality, hospital re-admissions, thromboembolic events, and bleeding are unknown and warrants further evaluation

Effects of D-allulose on glucose tolerance and insulin response to a standard oral sucrose load: results of a prospective, randomized, crossover study

Introduction Current dietary guidelines recommend limiting sugar intake for the prevention of diabetes mellitus (DM). Reduction in sugar intake may require sugar substitutes. Among these, D-allulose is a non-calorie rare monosaccharide with 70% sweetness of sucrose, which has shown anti-DM effects in Asian populations. However, there is limited data on the effects of D-allulose in other populations, including Westerners.Research design and methods This was a prospective, randomized, double-blind, placebo-controlled, crossover study conducted in 30 subjects without DM. Study participants were given a standard oral (50 g) sucrose load and randomized to placebo or escalating doses of D-allulose (2.5, 5.0, 7.5, 10.0 g). Subjects crossed-over to the alternate study treatment after 7–14 days of wash out. Plasma glucose and insulin levels were measured at five time points: before and at 30, 60, 90 and 120 min after ingestion.Results D-allulose was associated with a dose-dependent reduction of plasma glucose at 30 min compared with placebo. In particular, glucose was significantly lower with the 7.5 g (mean difference: 11; 95% CI 3 to 19; p=0.005) and 10 g (mean difference: 12; 95% CI 4 to 20; p=0.002) doses. Although glucose was not reduced at the other time points, there was a dose-dependent reduction in glucose excursion compared with placebo, which was significant with the 10 g dose (p=0.023). Accordingly, at 30 min D-allulose was associated with a trend towards lower insulin levels compared with placebo, which was significant with the 10 g dose (mean difference: 14; 95% CI 4 to 25; p=0.006). D-allulose did not reduce insulin at any other time point, but there was a significant dose-dependent reduction in insulin excursion compared with placebo (p=0.028), which was significant with the 10 g dose (p=0.002).Conclusions This is the largest study assessing the effects of D-allulose in Westerners demonstrating an early dose-dependent reduction in plasma glucose and insulin levels as well as decreased postprandial glucose and insulin excursion in subjects without DM. These pilot observations set the basis for large-scale investigations to support the anti-DM effects of D-allulose.Trial registration number NCT02714413