Search

A 21-year-old man presented with new-onset seizures and brain abscess. Echocardiography and cardiac magnetic resonance imaging revealed underlying Ebstein anomaly, secundum atrial septal defect, and cor triatriatum dexter. The elevated right heart pressures shunting through the septal defect and transient bacteremia were the likely mechanisms for his presentation. (Level of Difficulty: Intermediate.), Graphical abstract

Introduction: Left ventricular thrombus (LVT) is associated with high risk of major adverse cardiovascular events (MACE) and mortality. Although warfarin is standard of care for LVT prevention and treatment, there is rising interest in the role of direct oral anticoagulants (DOACs). The goal of this study is to evaluate clinical outcomes of patients with LVT treated with DOACs compared to those treated with warfarin. Methods: Patients within a regional, multi-center health care system diagnosed with LVT from 2014-2018 were retrospectively identified through search of the electronic medical record. Demographic data, comorbidities, anticoagulation treatment, ejection fraction, and LVT etiology were recorded. Clinical outcomes including LV thrombus resolution, bleeding, and all-cause mortality were determined. Results: Demographic data is summarized in Table 1. Of 212 identified patients, 140 (66%) were treated with warfarin, 57 (26.9%) with DOAC, and 7 (3.3%) with low molecular weight heparin. Of these, 158 (74.5%) were on concomitant antiplatelet therapy. One patient was treated with antiplatelet therapy alone, and 7 patients received neither anticoagulation nor antiplatelet therapy. Patients treated with DOAC had no significant differences compared to those treated with VKA with respect to LVT resolution (69.3% vs 64.9, p = 0.95), hemorrhagic stroke (2.1% vs 1.8%, p = 0.86), ischemic stroke (2.1% vs 3.5%, p = 0.58), significant bleed (9.2% vs 12.3%, p = 0.78), and all-cause mortality (13.6% vs 15.8%, p = 0.17). Conclusions: In this large, multi-center retrospective study, clinical outcomes and adverse events of patients treated with DOAC for LVT are similar to VKA-treated patients. Given the observational nature of this study, randomized controlled studies are needed to validate these findings.

Introduction: Despite data showing reductions in risk of death and heart failure hospitalization in heart failure patients with reduced ejection fraction (HFrEF), sacubitril/valsartan (SV) and mineralocorticoid-receptor antagonist (MRA) adoption rates have remained low. We hypothesized that instituting a quality initiative (QI) that prospectively identified SV/MRA candidacy in HFrEF patients and tied successful use of MRA/SV in eligible patients to total health system compensation would improve utilization rates. Methods: A HFrEF QI was implemented whereby a portion of a large outpatient cardiology practice’s total compensation by the health system was tied to successful SV and MRA use in HFrEF patients (EF25% SV use and >60% MRA use in eligible HFrEF patients, given the low rates of appropriate SV and MRA use nationally. Following QI introduction, patients with the above eligibility criteria were prospectively identified over one year. Providers were sent daily e-mails notifying them of eligible patients that day, and during the patient visit were prompted to complete a form, documenting use of SV, MRA, and/or any contraindications to their use including blood pressure, renal function, potassium level, ACE/ARB intolerance, or financial obstacles. To serve as a control arm, data was retrospectively collected on 6 months of consecutive HFrEF patients with the same eligibility criteria prior to QI initiation. Results: Of 1345 retrospectively identified HFrEF patients prior to initiating the QI, 855 (63.5%) and 964 (71.7%) met SV and MRA eligibility criteria. Of these, 324 (37.9%) were prescribed SV, 365 (37.9%) an MRA. Following QI implementation, 3792 patients with HFrEF were prospectively identified, and of these 2550 (67.2%) and 2589 (68.2%) met eligibility criteria for SV and MRA initiation. SV use in eligible patients increased from 37.9% pre-QI, to 72.1% post-QI (p < 0.001). MRA use increased from 37.9% pre-QI to 66.2% post-QI (p < 0.001). Conclusions: A quality initiative linking successful implementation of SV and MRA use in eligible HFrEF patients to physician compensation resulted in a significant increase in SV and MRA adoption rates.

The optimal management of patients with giant coronary aneurysms remains unclear and as such an individualized approach must be employed. A 52-year-old male presented with sudden onset chest pain. ECG revealed ST elevations in inferior leads. Emergent angiography showed a 17mm left main giant