Running a cardiology consult service during a pandemic: Experiences from the front lines

ABSTRACT: Millions of deaths worldwide have been attributed to the novel coronavirus (COVID-19). As case counts increased in the United States and resurgence occurred in Europe, health care systems across the country prepared for the influx of acutely ill patients. In response to this, our cardiology consult service was called to aid in the management of COVID-19 patients. We describe our experiences and the changes that were implemented

Expressive aphasia in a patient with recent dual-chamber cardioverter-defibrillator implantation: A preventable complication

Transvenous pacemaker and/or defibrillator lead placement into the left heart chambers is rarely done. Approximately a third of such cases reported in the literature presented with signs of thromboembolism, mostly neurological deficits. We describe a patient who presented with a cerebrovascular accident three months after inadvertent and unrecognized lead placement into the left atrium and ventricle through a sinus venosus atrial septal defect. Implant techniques to avoid this complication are discussed. (Cardiol J 2011; 18, 2: 197-199

LEFT ATRIAL COMPRESSION FROM ACHALASIA - THE DIAGNOSTIC POWER OF ECHOCARDIOGRAM

Background: Left atrial compression by an extracardiac mass can arise from multiple structures surrounding the heart. Differentials include hiatal hernias, mediastinal masses, dissecting aortic aneurysms, esophageal malignancies, and rarely esophageal abnormalities such as achalasia. We present a case of a patient who during a routine transthoracic echocardiogram (TTE) was found to have left atrial compression secondary to achalasia, determined using appropriate maneuvers during image acquisition. Case: A 69-year-old female with diabetes underwent a TTE as part of workup for labile, uncontrolled blood pressure. Simultaneously, she was also being worked up for symptoms of dysphagia, weight loss and chronic cough. TTE revealed a 3.3 x 5 cm heterogeneous extracardiac mass compressing the left atrium. Decision-making: To determine the source of the mass, she was given a carbonated beverage to drink during the imaging acquisition, which was seen within the mass with a change in echo density, confirming GI origin. Imaging with CT scan revealed a dilated esophagus, and furthermore, EGD and esophageal manometry confirmed a diagnosis of achalasia. Conclusion: Echocardiographic imaging, with appropriate maneuvers, can be effective in identifying masses of gastrointestinal origin, differentiating them from vascular or mediastinal origin. Echocardiography has shown to be a strong, non-invasive tool to not only diagnose cardiac diseases, but also extracardiac manifestations of various organ systems

PRIMARY CARDIAC BURKITT LYMPHOMA PRESENTING WITH ABDOMINAL PAIN

Background: Primary cardiac lymphomas are rare, carry high mortality rates and are often due to aggressive B cell lymphomas, including Burkitt Lymphoma (BL). BL is rare in the immunocompetent though more prevalent among AIDS patients. Case: A 41yo man with a history of alcohol abuse presented with 1 month of B-symptoms and abdominal pain. Initial labs found a positive HIV-1 antibody, elevated viral load and low CD4 count. CT chest and abdomen on arrival revealed a large infiltrating lobulated right atrial mass (RAM) (Figure 1A). Decision-making: Cardiac masses are often due to metastatic disease and warrant evaluation for extra-cardiac origin. TTE, TEE (Figures 1B & 1C) and cardiac magnetic resonance imaging identified a 2.8cm subcarinal lymph node and found the RAM to be infiltrating the inter-atrial septum, partially surrounding the pulmonary veins, obstructing the superior vena cava and extending to the aortic root (Figure 1D). Cytology of the subcarinal lymph node biopsy was consistent with BL. Highly active anti-retroviral therapy and chemotherapy were initiated. CT chest after 1 treatment cycle showed a marked reduction in RAM size (Figure 1E). Conclusion: Our case underscores the central role of advanced imaging in the evaluation of cardiac masses by identifying a malignant etiology, staging, identifying a target for pathologic diagnosis and monitoring treatment response. Early use of multimodality imaging for cardiac masses in the HIV population allows for timely use of lifesaving therapies

De Novo Occurrence of a Variant in ARL3 and Apparent Autosomal Dominant Transmission of Retinitis Pigmentosa.

BackgroundRetinitis pigmentosa is a phenotype with diverse genetic causes. Due to this genetic heterogeneity, genome-wide identification and analysis of protein-altering DNA variants by exome sequencing is a powerful tool for novel variant and disease gene discovery. In this study, exome sequencing analysis was used to search for potentially causal DNA variants in a two-generation pedigree with apparent dominant retinitis pigmentosa.MethodsVariant identification and analysis of three affected members (mother and two affected offspring) was performed via exome sequencing. Parental samples of the index case were used to establish inheritance. Follow-up testing of 94 additional retinitis pigmentosa pedigrees was performed via retrospective analysis or Sanger sequencing.Results and conclusionsA total of 136 high quality coding variants in 123 genes were identified which are consistent with autosomal dominant disease. Of these, one of the strongest genetic and functional candidates is a c.269A>G (p.Tyr90Cys) variant in ARL3. Follow-up testing established that this variant occurred de novo in the index case. No additional putative causal variants in ARL3 were identified in the follow-up cohort, suggesting that if ARL3 variants can cause adRP it is an extremely rare phenomenon

Hemodynamic and Echocardiographic Assessment of Left Ventricle Recovery with Left Ventricular Assist Devices: Do We Explant?

Introduction: Explantation of left ventricular assist devices (LVAD) after left ventricular (LV) recovery is estimated to occur in 1-2% of cases. Herein, we present a case of hemodynamic and echocardiographic assessment of LV recovery during outflow graft balloon occlusion leading to LVAD explantation. Case Report: A 56-year-old female with medical history of systolic heart failure due to non-ischemic cardiomyopathy with LVEF 25%. She underwent an urgent HeartMate 3 LVAD implant after an admission for cardiogenic shock. Post LVAD course was complicated by driveline infection. History was notable for admissions due to low-flow alarms in the setting of dehydration. On echocardiogram, progressive LVEF improvement was noted although with suboptimal images. CT angiography did not demonstrate any occlusion of the cannulas. Right heart catheterization showed stable cardiac index despite minimal flow on LVAD. Cardiopulmonary testing was favorable. After multi-disciplinary discussion, patient underwent LVAD wean study in the cath lab under hemodynamic and transesophageal echo (TEE) guidance with therapeutic anticoagulation. LVAD was turned off for 10 minutes with outflow graft occluded by Armada 14 mm x 20 cm peripheral balloon. Wiring of the outflow graft from aorta and balloon occlusion were visualized by TEE (Figure). The left and right ventricular function were similar to baseline with no change in mitral regurgitation. Cardiac index was normal (Figure). Patient subsequently underwent successful LVAD explant. She is doing well with NYHA class I symptoms and LVEF 45-50% noted upon 3-months follow-up LVAD explantation is a feasible option in LV recovery after appropriate hemodynamic and echocardiographic assessment. TEE is an essential tool, especially in patients with suboptimal windows. Outflow graft balloon occlusion can be used if there is concern about falsely poor results related to backflow or ongoing LVAD support at low speed leading to falsely improved results

TCT-378 Not Every TEE Is a “Standard of Care” TEE

Background: Intraprocedural structural heart imaging is more challenging and has unique differences from standard of care (SOC) imaging. However, the variations in time and complexity of different types of SOC transesophageal echocardiographs (TEEs) versus interventional TEEs is not well studied. In this study, we aim to compare the complexity of SOC nonvalvular indication TEE with SOC valvular TEE studies and interventional TEEs performed in the guidance of transcatheter edge-to-edge repair (TEER) MitraClip (Abbott Vascular) procedures. Methods: A retrospective case-control analysis was performed on 200 patients who underwent TEE in the Henry Ford Health System. One hundred cases of interventional TEE-guided TEER were compared with 73 nonvalvular (endocarditis and stroke evaluation) SOC TEEs and 27 valvular (preprocedural mitral, aortic, and tricuspid valve evaluations) SOC TEEs. Complexity was quantified by the total procedure duration, the total number of images, and the number of 3-dimensional (3D) clips captured. The mean, median, and SD were compared between these groups. The Kruskal-Wallis test was used to evaluate statistical significance. Results: The mean duration of TEE procedures, the number of images, and the number of 3D clips were all significantly higher in the interventional imaging TEER group compared with the noninterventional groups (P \u3c 0.0001) (Table 1). The duration and number of images were also significantly higher among valvular compared with nonvalvular SOC TEE groups (P \u3c 0.0002) as well as number of 3D clips (P \u3c 0.0012). Conclusion: Interventional TEE was more complicated and time-consuming compared with SOC TEE performed for both nonvalvular and valvular indications. The latter was also more complex than SOC nonvalvular TEE. This is the first study of its kind demonstrating objective differences between interventional and 2 SOC TEE groups. These results emphasize the need of dedicated training for intraprocedural imaging as well as restructuring of reimbursement codes. Categories: STRUCTURAL: Valvular Disease: Mitra

TCT-374 Structural Heart Intraprocedural Versus Nonprocedural Transesophageal Echocardiography: A Quantitative Analysis of Complexity

Background: Transesophageal echocardiography (TEE) is an essential tool in many structural heart procedures, such as transcatheter mitral valve edge-to-edge repair (TEER). Interventional procedural TEE requires a unique skill set. This study aims to evaluate the complexity of interventional structural heart TEE used to guide TEER compared with standard of care (SOC) TEE studies performed at a single center. Methods: A retrospective case-control analysis was performed of 200 patients who underwent TEE in the Henry Ford Health System. One hundred cases of interventional TEE-guided TEER were compared with 100 controls of SOC TEE. Complexity was quantified by the total duration of the procedure, the total number of images, and the number of 3-dimensional clips captured. The mean, median, and SD were compared between these 2 groups. Wilcoxon rank sum tests were used to evaluate statistical significance. Results: One hundred intraprocedural TEE studies to guide TEER and 100 SOC TEE studies were analyzed. The mean duration of TEE procedures, the number of images, and the number of 3-dimensional clips were all significantly higher in the TEER group (P \u3c 0.0001) (Table 1). Conclusion: Interventional TEE guidance for TEER is significantly more complex and more time-consuming than SOC TEE. This is the first large-scale study demonstrating objective differences between interventional and SOC TEE. This conclusion implicates the necessity of dedicated training programs for interventional imaging, in addition to the necessity of reviewing the current reimbursement codes to account for such a difference. Categories: STRUCTURAL: Valvular Disease: Mitra

Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative

A consensus conference on cardio-renal syndromes (CRS) was held in Venice Italy, in September 2008 under the auspices of the Acute Dialysis Quality Initiative (ADQI). The following topics were matter of discussion after a systematic literature review and the appraisal of the best available evidence: definition/classification system; epidemiology; diagnostic criteria and biomarkers; prevention/protection strategies; management and therapy. The umbrella term CRS was used to identify a disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ. Different syndromes were identified and classified into five subtypes. Acute CRS (type 1): acute worsening of heart function (AHF–ACS) leading to kidney injury and/or dysfunction. Chronic cardio-renal syndrome (type 2): chronic abnormalities in heart function (CHF-CHD) leading to kidney injury and/or dysfunction. Acute reno-cardiac syndrome (type 3): acute worsening of kidney function (AKI) leading to heart injury and/or dysfunction. Chronic reno-cardiac syndrome (type 4): chronic kidney disease leading to heart injury, disease, and/or dysfunction. Secondary CRS (type 5): systemic conditions leading to simultaneous injury and/or dysfunction of heart and kidney. Consensus statements concerning epidemiology, diagnosis, prevention, and management strategies are discussed in the paper for each of the syndromes