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Subclinical leaflet thrombosis is characterized by hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) on computed tomography. However, given the low incidence of HALT after TAVR, the clinical significance of HALT is still being investigated. We sought to generate a more reliable estimate of the risk factors and adverse outcomes associated with HALT after TAVR by pooling data from randomized trials and cohort studies. PubMed/Medline database was systematically searched from inception until November 24, 2021, using the following terms: ("hypoattenuated leaflet thickening" and "transcatheter aortic valve replacement") and ("Subclinical leaflet thrombosis" and "transcatheter aortic valve replacement"). A random effects model meta-analysis was conducted using Mantel-Haenszel odds ratios (ORs) and the associated 95% confidence intervals (CIs), mean difference and the associated 95%. Ten studies with a total of 1462 patients were included, with follow-up ranging between 4 months and 3 years. HALT occurred in 14.4% of the patients undergoing TAVR. HALT was not associated with increased risk of stroke/TIA (OR 1.38; 95% CI [0.61-3.11]; I2=0%) or increased risk of all-cause mortality (OR 0.67; 95% CI [0.25-1.80]; I2=0). HALT was associated with a greater post-procedural mean aortic valve gradient (mean difference 2.31 mmHg; 95% CI [0.27, 4.35]; I2=71%). Interestingly, there was a trend of higher risk of HALT in men (OR 1.37; 95% CI [0.82-2.30]; I2=44%) while there was a trend towards lower risk of HALT in the presence of CKD (OR 0.76; 95% CI [0.49-1.19]; I2=0%); these trends did not reach statistical significance. This meta-analysis shows that the occurrence of HALT following TAVR is associated with a greater post-procedural mean aortic valve gradient but no excess risk of death or cerebrovascular events. The clinical significance of this higher post-procedural mean aortic valve gradient is uncertain and requires further investigations.

A 63-year-old female with a history of hypertension presented with progressively worsening shortness of breath. She underwent a cardiac catheterization and was found to have prominent Thebesian veins as well as anomalous connections between the proximal right coronary artery and the right ventricle. Cardiac computed tomography was ordered for further evaluation and showed a coronary fistula to the right ventricular outflow tract confirming the diagnosis of a coronary-cameral fistula (CCF). CCF are rare congenital anomalous communications that occur between coronary arteries and a cardiac chamber. They are usually an incidental finding and patients are rarely symptomatic. As the use of coronary computed tomography angiography is rapidly expanding, the detection of CCF will likely increase in the general population.

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation >1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

“The show must go on” Proverbial—initially applied to the United States 1876 centennial celebrations and originally printed in The Morning Republican (Scranton, PA) on 13 December 1875. No other ti...

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease, making up 10% of all congenital heart defects. Annual follow-up echocardiograms are recommended in patients with repaired ToF, but evidence-based guidelines do not exist. We hypothesized that most echocardiograms performed in asymptomatic patients with repaired ToF and no physical exam change do not result in an actionable change (AC) in management. We retrospectively reviewed records of all patients with ToF and prior complete repair at our institution between January 2000 and September 2015. Changes in echocardiograms resulting in hospital admission, medication addition/change, cardiac catheterization, or surgical procedure were identified via chart review. These changes were referred to as an AC. A total of 1135 echocardiograms were reviewed from 233 patients (160 with initial complete repair, 70 with prior shunt, and 3 with other initial surgery). The median number of echocardiograms per patient was 5. Of the 1135 echocardiograms, 15 (1.3%) were associated with AC. Of the 15 patients with AC echocardiograms, 9 underwent a shunt prior to complete repair (9/70, 12.9%) and 6 had undergone an initial complete repair (6/160, 3.8%). The median age at AC was 6.3 years (IQR 4.4, 6.8) in the shunt group and 0.90 years (IQR 0.87, 1.1) in the initial complete repair group. In asymptomatic patients with repaired ToF and no physical exam change, echocardiograms rarely lead to a change in clinical management. In conclusion, the likelihood and timing of AC echocardiograms and reinterventions vary based on the type of initial surgery.

We have developed a high-speed 1310-nm Al-MQW buried-hetero laser having 29-GHz bandwidth (BW). The laser was used to compare 28-Gbaud four-level pulse-amplitude-modulation (PAM4) and 56-Gb/s nonreturn to zero (NRZ) transmission performance. In both cases, it was possible to meet the 10-km link budget, however, 56-Gb/s NRZ operation achieved a 2-dB better sensitivity, attributable to the wide BW of the directly modulated laser and the larger eye amplitude for the NRZ format. On the other hand, the advantages for 28-Gbaud PAM4 were the reduced BW requirement for both the transmitter and the receiver PIN diode, which enabled us to use a lower bias to the laser and a PIN with a higher responsivity, or conversely enable the possibility of high temperature operation with lower power consumption. Both formats showed a negative dispersion penalty compared to back-to-back sensitivity using a negative fiber dispersion of −60 ps/nm, which was expected from the observed chirp characteristics of the laser. The reliability study up to 11 600 h at 85 °C under accelerated conditions showed no decrease in the output power at a constant bias of 60 mA.

Cardiac resynchronization therapy is known to improve clinical outcomes in patients with heart failure and left ventricular dyssynchrony. However, the optimal positioning of the right ventricular lead is unknown, and there is conflicting data on the acute hemodynamic effects and long-term outcomes. Here, we present a case of a patient who underwent implantation of a dual-chamber pacemaker for complete heart block, but who after three months, still had symptoms consistent with New York Heart Association (NYHA) Class IV heart failure. After optimal medical therapy failed and a left ventricular lead was placed, he still remained symptomatic, so the right ventricular lead was repositioned from the right ventricular outflow tract to the right ventricular apex. Afterwards, the patient’s symptoms improved from NYHA Class IV to NYHA Class II, and his left ventricular ejection fraction improved from 20% to 45%.

Background New onset post-operative atrial fibrillation (POAF) can complicate both non-cardiac(NCS) and cardiac(CS) surgeries. Long term differences in recurrence of atrial fibrillation (AF) and incidence of ischemic stroke/transient ischemic attack(CVA)between these types of POAFare lacking. Objective To compare thelong term recurrence rate of AF and incidence of CVAin patients withnew onset POAF after CS and NCS. Methods All patients who developed POAF between May 2010 and April 2014 were included in this single-center, retrospective study Exclusion criteria included a prior history of atrial tachyarrhythmias and pre-operative use of anti-arrhythmic drugs. Recurrence of atrial fibrillation and CVA was identified by review of medical records, electrocardiogram and Holter monitor. Results patients identified by the ICD9 code=523, 112 patients (61 cardiac; 51 non-cardiac) met inclusion criteria. Mean follow up was 943 days (range 32-2052 days).AF recurrence rate within 30 days after hospital discharge was higher in CS compared with NCS(10% vs 0%, p =0.03). Kaplan Meier analysis showed a trend towards higher recurrence in NCS compared with CS(HR 2.8; 95% CI 0.78-10.6, log rank p =0.03).In long term follow-up, CVA was numerically more common in patients with POAF after CS compared withNCS(10% vs 2%) though this difference was non-significant(HR 3.1; 95% CI 0.72-13.3; log rank p =0.26). Conclusion The risk of recurrent AF and ischemic stroke is not different between POAF after CS or NCS. The overall high rate of AF recurrence and risk of ischemic stroke mandate careful long term follow-up.

Presently described is a case of disseminated adenovirus infection in a heart-kidney transplant recipient that was successfully treated with cidofovir. There are several reports of adenovirus infections in adult solid organ transplant recipients and the prognosis is usually poor, with mortality rates of 40% to 60%. Severe disseminated adenovirus infections have been associated with increased risk of adverse transplant events, such as rejection, ventricular dysfunction, allograft vasculopathy, graft loss, and the need for re-transplantation. The patient's lack of clinical improvement, the onset of hemorrhagic cystitis and acute kidney injury were factors in our decision to temporarily discontinue administration of immunosuppressive agents and start an antiviral agent. It is important to suspect adenovirus in transplant patients when they do not respond to antibiotics and cultures are negative. Early diagnosis and treatment are critical to improving outcomes in immunocompromised patients.

OBJECTIVE The clinical value of low-intensity pulsed ultrasound (LIPUS) for fresh fracture is known. Yet, in the absence of a definition of what "fresh" is, payers have adopted study inclusion criteria drawn from randomized clinical trials as de facto definitions of which patients should be treated, with "fresh" defined as

The manifestation of atrial flutter, particularly with 1:1 conduction, is rare in patients with ventricular preexcitation secondary to Wolff-Parkinson-White Syndrome (WPW). Very few cases have been reported in the literature. We present a 40-year old male with a history of untreated WPW who presented with severe chest pain and shortness of breath. He was found to have a rapid, regular, wide complex tachycardia. He underwent successful synchronized cardioversion, in which the patient converted tonormal sinus rhythm with classic WPW waveform characteristics, including a shortened PR interval and prolonged QRS complex with a slurred upstroke. Surprisingly, a subsequent electrophysiology study revealed atrial flutter, with bystander conduction of 1:1 atrial flutter being the most likely cause of the patient’s presenting symptoms, and a posteroseptal accessory pathway consistent with the diagnosis of WPW. While considerably rarer than ventricular tachycardia or AVRT, it is nevertheless important for clinicians to consider atrial flutter with 1:1 conduction as a potential diagnosis in patients with WPW presenting with wide complex tachycardia.

We present a patient with mitochondrial myopathy who developed rhabdomyolysis following treatment with clindamycin. While clindamycin is not yet linked to drug-induced rhabdomyolysis in the literature, other drugs with mechanisms of action similar to clindamycin have been shown to damage human host mitochondria. Given this, we contend that clindamycin may also be capable of causing mitochondrial injury, and that while in otherwise healthy patients it may not produce any negative clinical outcome, it can precipitate rhabdomyolysis in certain patients whose mitochondria are already vulnerable.

Methimazole (MMI) is a commonly used medication in the treatment of hyperthyroidism. The side effect profile is extensive and includes the rare but serious side effect of drug associated liver injury. We report the case of a 51-year-old female who presented with painless jaundice several weeks after initiating MMI therapy for treatment of hyperthyroidism complicated by Graves’ orbitopathy. Liver function tests on presentation showed alanine aminotransferase (ALT) 1366 IU/L, aspartate aminotransferase (AST) 853 IU/L, total bilirubin 26.2 mg/dl, alkaline phosphatase 954 IU/L. Workup of structural, infectious, and autoimmune causes of hepatic injury was negative. The patient was therefore found to have MMI associated liver injury. MMI was discontinued and the patient was started on ursodiol, resulting in resolution of her jaundice and improvement of her liver function tests.

Purpose The ASA score (Age > 60 yo, serum sodium Methods We reviewed records of patients discharged on palliative inotropes who were not candidates for LVAD or heart transplant and calculated their ASA ‘point’ score. The effect of ASA score on survival was estimated and tested for statistical significance using a Cox proportional hazards regression model. In addition, Kaplan-Meier lifetable analysis was used to generate the figure and the log-rank p-value. Results A total of 72 patients from 2009 - 2017 met the inclusion criteria. (75% male, mean age 64, 75% white.) A point was assigned for each of the three components of the ASA score and each patient was scored from 0 to 3. As seen on the figure below, this score provides highly significant discrimination between patients with excellent survival at one year and those with progressively worse survival. (p=0.002) Conclusion The ASA score is a simple three component score that stratifies patients that are at low, medium and high risk for death on chronic inotropic therapy. Our analysis suggests that this score is a reliable way to assess mortality in patients receiving palliative inotropic therapy. However, further research is necessary to independently validate the score in a larger population.

We present successful transmission of 52Gb/s PAM4 through −58 and +10 ps/nm of SMF using a single chip and directly modulated laser. The receiver sensitivities are compared using APD and PIN PD at the receiver.

A highly diastereoselective protocol for the formal nucleophilic substitution of 2-bromocyclopropylcarboxamides with azoles is described. A wide range of azoles, including pyrroles, indoles, benzimidazoles, pyrazoles, and benzotriazoles, can be efficiently employed as pronucleophiles in this transformation, providing expeditious access to N-cyclopropyl heterocycles.

Introduction: Statins have been shown to effectively prevent both cardiovascular morbidity and mortality by inhibiting the hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase enzyme. Pulmonary complications are very rare, and can include pneumonitis, pleural effusion, and nonspecific interstitial pneumonia (NSIP). There have been very few previously documented cases of statin-induced fibrotic NSIP.Case report: We present a female with a history of hyperlipidemia on atorvastatin who presented with shortness of breath. Computed tomography scan of the chest revealed interstitial infiltrates with bilateral ground-glass opacities. She underwent a surgical lung biopsy which showed uniform fibrous alveolar septal thickening, scattered collections of alveolar macrophages and inflammation, along with areas of fibrosis. The findings were most suggestive of fibrotic NSIP. Atorvastatin was stopped and she was started on mycophenolic acid with improvement of her symptoms.Discussion: Although rare, the clinician should be aware of possible pulmonary complications of statin therapy. The exact mechanism of injury is unclear, however immunological or toxicological mechanisms are implicated. One case series of statin induced interstitial lung disease showed some improvement of dyspnea with systemic glucocorticoids and termination of statin therapy. Statins, specifically pravastatin, lovastatin, and simvastatin have been associated with drug induced pneumonitis and interstitial lung disease.

Background: Lambl’s excrescences (LEx) are thin, filiform structures that arise on the lines of closure of heart valves. Although rare, we have come across various case reports in the literature describing thromboembolic events associated with LEx. We report the case of a 63-year-old female who presented with TIA-like symptoms and was found to have a LEx on the aortic side of native aortic valve. We conducted a comprehensive literature review with emphasis on different therapeutic strategies utilized to provide insight for future encounters.Case presentation: A 63-year-old female with a past medical history significant for hypertension and hyperlipidemia presented to the emergency room with symptoms of dysarthria and unsteady gait. While in the hospital, the patient returned to her baseline gait and speech without intervention. Work-up for including computed tomography of the head, magnetic resonance imaging, and carotid doppler, as well as prolonged telemetry monitoring was negative. A transthoracic echocardiogram showed a 0.81 cm linear echodensity attached to the aortic side of the aortic valve, highly suggestive of LEx that was later confirmed on transesophageal echocardiogram. Patient was placed on clopidogrel alone for antiplatelet therapy due to an aspirin allergy and she was subsequently discharged home.Discussion: No standard management for LEx currently exists. We aim to add to the evidence of effective management and explore the literature of patients who have experienced TIA/CVA symptoms secondary to LEx.

DAP-related apoptotic kinase-2 (DRAK2), a death-associated protein kinase family member, is highly expressed in B and T lymphocytes in the human and the mouse. To determine whether DRAK2 plays a role in B-cell activation and differentiation, we analyzed germinal centers (GCs) and the specific antibody response to NP in drak2-/- mice immunized with the thymus-dependent (TD) conjugated hapten NP16-CGG. In drak2-/- mice, spleen GCs were normal in size and morphology, but their number was reduced by as much as 5-fold, as compared to their wild-type littermates. This was not due to a defect in B-cell proliferation, as the BrdU uptake was comparable in DRAK2-deficient and wild-type B cells. Rather, the proportion of apoptotic GC B and T cells in drak2-/- mice was significantly higher than that in wild-type control mice, as shown by 7-AAD and terminal deoxynucleotide transferase dUTP nick end labeling (TUNEL) staining. In drak2-/- mice, the generation high affinity IgG antibodies was impaired in spite of the seemingly normal somatic hypermutation and class switch DNA recombination machineries in drak2-/- B cells. In NP16-CGG-immunized drak2-/- mice, T-cell-intrinsic Bcl-xL transgene expression increased the number of GCs and rescued the high affinity IgG response to NP. These findings suggest a novel role for DRAK2 in regulating the GC reaction and the response to TD antigens, perhaps through increased survival of T cells and enhanced B-cell positive selection. They also suggest that DRAK2-deficiency is not involved in regulating intrinsic B-cell apoptosis.

Background Of eight cases of Legionella infection in pregnancy reported over 35 years, there was one case of maternal septic shock with poor outcome, one recovery with good outcome, and six with poor outcome. Case A 30-year-old woman, gravida 2 para 1, at 28 weeks of gestation presented with a high fever, cough, nausea, and vomiting. She deteriorated despite treatment for presumed urosepsis, was transferred to the intensive care unit, and remained intubated for 10 days receiving cardiovascular support, antivirals, antifungals, and multiple wide-spectrum antibiotics. Legionella infection antigen testing was performed on hospital day 1 and returned as positive. Azithromycin, started before the testing results became available, was continued for 14 days. The patient recovered, and the pregnancy progressed uneventfully to term. Conclusion Legionella infection should be considered with maternal deterioration despite broad-spectrum antibiotic coverage. A favorable outcome is possible with early diagnosis and treatment.

Background: A Brodie abscess is a rare subtype of subacute osteomyelitis which can be acquired from local trauma or hematogenous spread secondary to transient bacteremia. However, to date there have been no reports of the presence of a Brodie abscess in the mandible.Case representation: Here we report a case of a 51-year-old female who presented to the emergency department with a 4-day history of left sided facial pain and trismus after recent dental manipulation. A computed tomography (CT) scan showed the presence of osteomyelitis with a Brodie abscess in the mandibular condyle. Empiric treatment was initiated with ampicillinsulbactam. After seven days of treatment, the antibiotics were switched to ceftriaxone and metronidazole on discharge. Five days later the patient returned to the hospital with the same symptoms that she initially presented with, indicating a failure of treatment. Follow-up CT scan showed the persistence of the Brodie abscess. Subsequently, IV ertapenem was initiated for a duration of eight weeks and the patient was instructed to obtain an oral surgery evaluation as an outpatient.Conclusions: This case highlights a unique presentation of a Brodie abscess, which has been previously exclusively found in long bones, and raises awareness of such a complication in patients whose facial erythema, pain, and swelling may not improve with first line therapy for a simple dental infection. Additionally, we highlight that the unique location of the mandibular condyle poses a treatment challenge and surgical replacement of the jaw appears to be the lone curative modality.