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Medicina (Kaunas, Lithuania) Jun 2023: Atrial flutter is an infrequent yet potentially fatal arrhythmia. Digoxin is the preferred first-line treatment for fetal atrial flutter due to its efficacy and...
: Atrial flutter is an infrequent yet potentially fatal arrhythmia. Digoxin is the preferred first-line treatment for fetal atrial flutter due to its efficacy and favorable safety profile. The optimal digoxin serum target level for neonatal atrial flutter management remains uncertain, with the standard target level ranging from 1.0 to 2.0 ng/mL due to potential toxicity concerns above this threshold. : We present a case of atrial flutter in a fetus within a monochorionic diamniotic (MCDA) twin pregnancy that was successfully managed using a higher-than-standard target level of digoxin. A 34-year-old nulliparous woman was referred to our institution at 31 + 3 weeks of gestation due to fetal distress in an MCDA twin pregnancy. Fetal echocardiography revealed a ventricular rate of 214 bpm in twin A, while twin B exhibited no abnormal findings. : Our case highlights a distinct correlation between the serum digoxin level and its impact on atrial flutter. A higher target serum level of digoxin may be necessary to achieve sinus conversion due to the unique maternal and fetal circulatory characteristics in MCDA pregnancies.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Adult; Atrial Flutter; Digoxin; Pregnancy, Twin; Twins; Echocardiography; Retrospective Studies
PubMed: 37512010
DOI: 10.3390/medicina59071198 -
Scientific Reports Jul 2023Pectus excavatum (PE) is a congenital malformation with a funnel-shaped depression of the sternum that can lead to cardiac symptoms. However, there are patients with...
Pectus excavatum (PE) is a congenital malformation with a funnel-shaped depression of the sternum that can lead to cardiac symptoms. However, there are patients with thoracic constriction (defined as elevated Haller-Index > 3.25 determined by cardiac magnetic resonance imaging (CMR)) without visible evidence of PE, leading to similar complaints. Between January 2004 till June 2020, patients who underwent CMR for further evaluation of the heart, due to cardiac symptoms were enrolled and compared to controls. Biventricular global strain analysis was assessed using feature tracking (CMR-FT). ECG and/or Holter recordings were performed to detect rhythm events. Cardiac symptoms were evaluated in detail using a questionnaire. Finally, 88 patients (male 35, female 53) with elevated Haller-Index (3.9 ± 0.8) were included and compared to CMR data from 25 individuals with confirmed PE and 25 healthy controls (HC). Mean age at time of CMR was 35 ± 16 years. The most common symptoms at presentation were palpitations (41%), followed by dyspnea (24%) and atypical chest pain (14%). Three patients (3%) had atrial fibrillation or atrial flutter. Concomitant phenomena were pericardial effusion in 39% and mitral valve prolapse (MVP) in 27% of the study cohort. While there were no differences in left ventricular function or volumes, right ventricular function (RVEF) was significantly lower in patients with internal PE compared to HC (RVEF (%) 50 ± 5 vs 59 ± 4, p < 0.01). Strain analysis revealed only discrete changes in RV strain, implying a purely mechanical problem in the absence of structural changes. RV dimensions were negatively correlated with the size of thoracic indices (r = 0.41), reflecting the extent of thoracic constriction. MVP was more prevalent in patients with greater thoracic indices (r = 0.24). The described cohort, referred to as internal PE because of the absence of external changes, showed similar CMR morphologic findings as patients with real PE (especially altered dimensions of the right heart and a lower RVEF). In addition, there was a high incidence of rhythm disturbances, such as extrasystoles or arrhythmias. In one-third of the study cohort additional abnormalities such as pericardial effusion or MVP were present, with MVP being found more frequently in patients with larger thoracic indices, suggesting a possible common pathogenesis.Trial registration: ISRCTN registry, ISRCTN15355937, retrospectively registered 03.06.2022, https://www.isrctn.com/ISRCTN15355937?q=15355937&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10 .
Topics: Humans; Male; Female; Young Adult; Adult; Middle Aged; Funnel Chest; Pericardial Effusion; Constriction; Magnetic Resonance Imaging; Heart; Mitral Valve Prolapse; Magnetic Resonance Imaging, Cine
PubMed: 37491452
DOI: 10.1038/s41598-023-38739-w -
Journal of the American Heart... Aug 2023Background We aim to compare the burden of cardiovascular disease risk factors and major adverse cardiac events and in-hospital outcomes among young Black patients (aged...
Background We aim to compare the burden of cardiovascular disease risk factors and major adverse cardiac events and in-hospital outcomes among young Black patients (aged 18-44 years) hospitalized in 2007 and 2017 using data obtained from the National Inpatient Sample database. Method and Results Comparison of the sociodemographic characteristics, comorbidities, and inpatient outcomes, including major adverse cardiac events (all-cause mortality, acute myocardial infarction, cardiogenic shock, cardiac arrest, ventricular fibrillation/flutter, pulmonary embolism, and coronary intervention), between 2017 and 2007 was performed. Multivariable analyses were performed, controlling for potential covariates. A total of 2 922 743 (mean age, 31 years; 70.3% women) admissions among young Black individuals were studied (1 341 068 in 2007 and 1 581 675 in 2017). The 2017 cohort had a younger population (mean, 30 versus 31 years; <0.001), more male patients (30.4% versus 28.8%; <0.001), and patients with higher nonelective admissions (76.8% versus 75%; <0.001), and showed an increasing burden of traditional cardiometabolic comorbidities, congestive heart failure, chronic pulmonary disease, coagulopathy, depression, along with notable reductions in alcohol abuse and drug abuse, compared with the 2007 cohort. The adjusted multivariable analysis showed worsening in-hospital outcomes, including major adverse cardiac events (adjusted odds ratio [aOR], 1.21), acute myocardial infarction (aOR, 1.34), cardiogenic shock (aOR, 3.12), atrial fibrillation/flutter (aOR, 1.34), ventricular fibrillation/flutter (aOR, 1.32), cardiac arrest (aOR, 2.55), pulmonary embolism (aOR, 1.89), and stroke (aOR, 1.53). The 2017 cohort showed a decreased rate of percutaneous coronary intervention/coronary artery bypass grafting and all-cause mortality versus the 2007 cohort (<0.001). Conclusions In conclusion, young Black patients have had an increasing burden of cardiovascular disease risk factors and worsened in-hospital outcomes, including major adverse cardiac events and stroke, in the past decade, although with improved survival odds.
Topics: Humans; Male; Female; Adult; Cardiovascular Diseases; Shock, Cardiogenic; Ventricular Fibrillation; Myocardial Infarction; Stroke; Heart Arrest; Pulmonary Embolism; Hospital Mortality
PubMed: 37489730
DOI: 10.1161/JAHA.123.029895 -
Frontiers in Cardiovascular Medicine 2023Pre-existing cardiovascular disease and cardiovascular risk factors are common in patients with COVID-19 and there remain concerns for poorer in-hospital outcomes in...
BACKGROUND
Pre-existing cardiovascular disease and cardiovascular risk factors are common in patients with COVID-19 and there remain concerns for poorer in-hospital outcomes in this cohort. We aimed to analyse the relationship between pre-existing cardiovascular disease, mortality and cardiovascular outcomes in patients hospitalised with COVID-19 in a prospective, multicentre observational study.
METHOD
This prospective, multicentre observational study included consecutive patients of age ≥18 in their index hospitalisation with laboratory-proven COVID-19 in Australia. Patients with suspected but not laboratory-proven COVID-19 and patients with no available past medical history were excluded. The primary exposure was pre-existing cardiovascular disease, defined as a composite of coronary artery disease, heart failure or cardiomyopathy, atrial fibrillation or flutter, severe valvular disease, peripheral arterial disease and stroke or transient ischaemic attack. The primary outcome was in-hospital mortality. Secondary outcomes were clinical cardiovascular complications (new onset atrial fibrillation or flutter, high-grade atrioventricular block, sustained ventricular tachycardia, new heart failure or cardiomyopathy, pericarditis, myocarditis or myopericarditis, pulmonary embolism and cardiac arrest) and myocardial injury.
RESULTS
1,567 patients (mean age 60.7 (±20.5) years and 837 (53.4%) male) were included. Overall, 398 (25.4%) patients had pre-existing cardiovascular disease, 176 patients (11.2%) died, 75 (5.7%) had clinical cardiovascular complications and 345 (37.8%) had myocardial injury. Patients with pre-existing cardiovascular disease had significantly increased in-hospital mortality (aOR: 1.76 95% CI: 1.21-2.55, = 0.003) and myocardial injury (aOR: 3.27, 95% CI: 2.23-4.79, < 0.001). There was no significant association between pre-existing cardiovascular disease and in-hospital clinical cardiovascular complications (aOR: 1.10, 95% CI: 0.58-2.09, = 0.766). On mediation analysis, the indirect effect and Sobel test were significant ( < 0.001), indicating that the relationship between pre-existing cardiovascular disease and in-hospital mortality was partially mediated by myocardial injury. Apart from age, other cardiovascular risk factors such as diabetes, hypercholesterolemia and hypertension had no significant impact on mortality, clinical cardiovascular complications or myocardial injury.
CONCLUSIONS
Pre-existing cardiovascular disease is associated with significantly higher mortality in patients hospitalised with COVID-19. This relationship may be partly explained by increased risk of myocardial injury among patients with pre-existing cardiovascular disease which in turn is a marker associated with higher mortality.
PubMed: 37476577
DOI: 10.3389/fcvm.2023.1224886 -
Journal of Clinical Medicine Jun 2023Unlike atrial fibrillation (AF), atrial flutter (AFl) is thought to be relatively refractory to pharmacological cardioversion (PC), but the evidence is scarce. The aim...
BACKGROUND
Unlike atrial fibrillation (AF), atrial flutter (AFl) is thought to be relatively refractory to pharmacological cardioversion (PC), but the evidence is scarce. The aim of this study was to evaluate the clinical characteristics and efficacy of the PC of AFl with amiodarone in comparison to AF.
MATERIALS AND METHODS
This retrospective study covered 727 patients with urgent consult for AF/AFl in a high-volume emergency department between 2015 and 2018. AFl was diagnosed in 222 (30.5%; median age: 68 (62; 75) years; 65.3% men). In a nested case-control study, 59 control patients with AF, matched in terms of age and sex with 60 AFl patients, were subject to PC with amiodarone. The primary endpoint was return of sinus rhythm confirmed using a 12-lead ECG.
RESULTS
The AFl population had a median CHA2DS2-VASc score of 3 (2; 4) and episode duration of 72 h (16; 120). In the AFl cohort, 36% of patients were initially subject to PC, 33.3% to electrical cardioversion (EC) and 40.5% to catheter ablation. In comparison to the AF group, the AFl patients required a longer hospitalization time, had a higher rate of EC ( < 0.001) and less frequent use of PC ( < 0.001) and, lower left ventricular ejection fraction ( < 0.001) and more pronounced cardiovascular risk factors. The efficacy of PC with amiodarone was significantly lower in AFl than AF group (39% vs. 65%, relative risk (RR) 0.60, = 0.007).
CONCLUSIONS
AFl patients shared a greater burden of comorbidities than AF patients, while the efficacy of PC in AFl was low. Patients should be initially managed with primary electrical cardioversion.
PubMed: 37445297
DOI: 10.3390/jcm12134262 -
Cureus Jun 2023Durvalumab is a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). It has been recently approved for the treatment of advanced urothelial and...
Durvalumab is a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). It has been recently approved for the treatment of advanced urothelial and non-small cell lung cancer (NSCLC) with a more favorable side effect profile compared to traditional chemotherapy agents. We present a case of durvalumab-induced myocarditis complicated by complete heart block (CHB). A 71-year-old male with a history of atrial flutter status post ablation, type 2 diabetes mellitus, hypertension, and non-small cell lung carcinoma (NSCLC) recently started on durvalumab, presented with new sinus bradycardia on electrocardiogram (EKG). His initial labs were notable for a troponin T of 207 ng/L (normal range ≤50). Transthoracic echo (TTE) and computed tomography angiography (CTA) of the coronaries were unremarkable. The hospital course was complicated by CHB on telemetry for 15 minutes. Given hemodynamic instability, cardiac magnetic resonance imaging (MRI) could not be obtained. The patient received transvenous pacing. Electrophysiology and cardiology-oncology were consulted to evaluate for pacemaker implantation as well as management for durvalumab-induced myocarditis. Methylprednisolone 1000 mg intravenous (IV) was started with an improvement in troponin levels but without improvement in CHB. His course was further complicated by polymorphic ventricular tachycardia prompting the placement of a permanent dual-chamber pacemaker. The patient was discharged on a prednisone taper, and durvalumab was discontinued. A diagnosis of durvalumab-induced myocarditis was made based on elevated troponin levels, with the exclusion of coronary artery disease with CTA of the coronaries. The persistence of conduction abnormalities despite treatment with steroids leads to the placement of a permanent pacemaker. Durvalumab falls under the category of immune checkpoint inhibitor (ICI) therapy which are novel agents that have more favorable side effect profiles compared to traditional chemotherapeutic agents. A review of the literature shows myocarditis with arrhythmias as a potentially rare side effect of ICI therapy. Corticosteroid therapy seems to be promising as a potential therapy.
PubMed: 37431327
DOI: 10.7759/cureus.40171 -
Journal of Cardiovascular Echography 2023Sinus of Valsalva pseudoaneurysm (SVpA) is a rare cause of right ventricular inflow obstruction. We report such a case presented with atrial flutter and cardiogenic...
Sinus of Valsalva pseudoaneurysm (SVpA) is a rare cause of right ventricular inflow obstruction. We report such a case presented with atrial flutter and cardiogenic shock caused by tricuspid valve obstruction by a narrow-necked right SVpA complicating aortic valve infective endocarditis demonstrated on transesophageal echocardiography and cardiac computed tomography. Despite restoration of sinus rhythm, the patient ran a fatal course due to aneurysmal rupture. We show the value of transesophageal echocardiography in evaluating unstable patients with cardiogenic shock, and the need of urgent surgery in selected patients to avoid a dismal outcome.
PubMed: 37426721
DOI: 10.4103/jcecho.jcecho_64_22 -
Cureus Jun 2023Over the past seven decades, significant advancements and innovations have occurred in the field of percutaneous atrial septal defect (ASD) closure using... (Review)
Review
Over the past seven decades, significant advancements and innovations have occurred in the field of percutaneous atrial septal defect (ASD) closure using transcatheter-based devices. This article focuses on the current literature surrounding the three Food and Drug Administration (FDA)-approved devices for ASD and patent foramen ovale (PFO) closure in the United States, namely, the Amplatzer Septal Occluder (ASO), Amplatzer Cribriform Occluder, and Gore Cardioform ASD Occluder. The ASO has been widely used since its FDA approval in 2001. Studies have shown its high success rate in closing ASDs, especially small-sized defects. The RESPECT trial demonstrated that PFO closure using the ASO reduced the risk of recurrent ischemic stroke compared to medical therapy alone. The Closure of Atrial Septal Defects With the Amplatzer Septal Occluder Post-Approval Study (ASD PMS II) evaluated the safety and effectiveness of ASO in a large cohort of patients, reporting a high closure success rate and rare hemodynamic compromise. The Amplatzer Cribriform Occluder is designed for the closure of multifenestrated ASDs and has shown promising results in small-scale studies. It successfully closed the majority of fenestrated ASDs, leading to improved right ventricular diastolic pressure without major complications. The REDUCE trial compared PFO closure using the Gore Helex Septal Occluder and Gore Cardioform Septal Occluder with antiplatelet therapy alone. The study demonstrated that PFO closure significantly reduced the risk of recurrent stroke and brain infarction compared to antiplatelet therapy alone. However, the closure group had a higher incidence of atrial fibrillation or atrial flutter. There is a risk of atrial fibrillation with the use of ASO as well. The FDA-approved Gore Cardioform ASD Occluder showed excellent performance in the ASSURED clinical study. The device achieved high technical success and closure rates, with low rates of serious adverse events and device-related complications. A meta-analysis comparing transcatheter ASD closure with surgical closure revealed that the transcatheter approach had a high success rate, lower rates of adverse events, and shorter hospital stays compared to surgery, without any mortality. Complications associated with transcatheter ASD closure have been reported, including femoral arteriovenous fistulas, device embolization, cardiac erosion, aortic incompetence, and new-onset migraine. However, these complications are relatively rare. In conclusion, transcatheter ASD closure using FDA-approved devices has proven to be safe and effective in the majority of cases. These devices offer excellent closure rates, reduced risk of recurrent stroke, and shorter hospital stays compared to surgery. However, careful patient selection and follow-up are necessary to minimize complications and ensure optimal outcomes.
PubMed: 37425612
DOI: 10.7759/cureus.40132 -
Journal of the American Heart... Jul 2023Background Stroke incidence is elevated after acute coronary syndromes (ACS). The aim of this study was to characterize risk factors related to ischemic stroke (IS)...
Background Stroke incidence is elevated after acute coronary syndromes (ACS). The aim of this study was to characterize risk factors related to ischemic stroke (IS) after ACS. Methods and Results We conducted a retrospective registry study based on the data of 8049 consecutive patients treated for ACS between 2007 and 2018 in Tays Heart Hospital with a follow-up until December 31, 2020. Potential risk factors were identified by in-depth review of written hospital records and causes-of-death registry data maintained by Statistics Finland. The association between individual risk factors, early-onset IS (0-30 days after ACS, n=82), and late-onset IS (31 days to 14 years after ACS, n=419) were analyzed using logistic regression and subdistribution hazard analysis. In multivariable analysis, the most substantial risk factors for early- and late-onset IS were previous stroke, atrial fibrillation or flutter, and heart failure status depicted by the Killip classification. Left ventricular ejection fraction and coronary artery disease severity were significant risk factors for early-onset IS; age and peripheral artery disease were significant risk factors for late-onset IS. The risk of early-onset IS with ≥6 CHADS-VASc score points (odds ratio, 6.63 [95% Cl, 3.63-12.09]; <0.001) was notable compared with patients with 1 to 3 points as well as the risk of late-onset IS with ≥6 points (subdistribution hazard, 6.03 [95% Cl, 3.71-9.81]; <0.001) in comparison with patients with 1 point. Conclusions Factors related to high thromboembolic risk also predict IS risk after ACS. CHADS-VASc score and its individual components are strong predictors for both early- and late-onset IS.
Topics: Humans; Acute Coronary Syndrome; Ischemic Stroke; Retrospective Studies; Stroke Volume; Ventricular Function, Left; Risk Factors; Stroke; Atrial Fibrillation; Risk Assessment
PubMed: 37421266
DOI: 10.1161/JAHA.122.028787