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Post-myocardial infarction ventricular septal rupture (MI-VSR) remains a dreadful complication with dismal prognosis. Surgical repair is the primary treatment strategy, whereas the role of heart transplantation (HT) as a primary option in MI-VSR is limited to case reports (CRs). We performed a systematic review of CRs to describe in-hospital mortality, and survival at 6 and 12 months in adult patients with MI-VSR treated with HT as a primary or bailout strategy. We performed a comprehensive search of Web of Science, PubMed, and Ovid Medline. The last search was completed on March 10, 2020. An aggregated score based on the CARE case report guideline was used to assess the quality of the CRs. We included CRs that described adult patients with MI-VSR treated with HT as a primary or bailout strategy. A total of 14 CRs between 1994 and 2015 were included, retrieving and analyzing the characteristics of 17 patients. A total of 12 patients underwent HT, with HT being the primary strategy in 8 patients and a bailout strategy for 4 patients following initial surgical repair, while 5 patients died awaiting HT under mechanical circulatory support (MCS), accounting for the total in-hospital mortality of this series (29%). Regarding long-term outcomes, 6 patients were reported to be alive at 6 months and 1 year after HT, while information was missing in the remaining 6 patients. In conclusion, HT supported by the use of temporary and durable MCS as a bridge to HT could be a feasible primary or bailout strategy to reduce the high in-hospital mortality of patients with MI-VSR.

Left atrial appendage occlusion using the Watchman device has emerged as an alternative treatment strategy for preventing strokes in patients with atrial fibrillation. However, there is no data on its safety and clinical outcomes in prior renal or liver transplant recipients. We included a total of 61,995 patients from the National Inpatient Sample (NIS, in-hospital outcomes) and 55,048 patients from the National Readmission Database (NRD, 30-day outcomes) who underwent percutaneous left atrial appendage occlusion (LAAO). From this group, 0.65% (n=405) and 0.62% (n=339) were renal and liver transplant recipients in NIS and NRD respectively. Transplant recipients were younger compared with non-transplant recipients (mean age 69 vs 77 years, P=0.01). There was little difference in terms of in-hospital mortality (0% vs 0.2%, P=0.43), major complications (6.2% vs 5.6%, P=0.61), cardiovascular complications (2.5% vs 2.8%, P=0.73), neurological complications (1.2% vs 0.7%, P=0.21) or bleeding complications (1.2% vs 0.7%, P=0.99) between transplant vs. non-transplant patients. Based on the NRD database, 30-day readmission rate was not meaningfully different for transplant recipients undergoing LAAO (9.44%) when compared to non-transplant patients (8.12%, [log-rank, P=0.56]). There was no difference between 30-day major or cardiovascular complications, however vascular complication rates were significantly higher for transplant recipients (OR 2.56, 95% CI [(1.66-3.47]). Our study findings suggest that LAAO may be safe for patients with a prior renal or liver transplant in terms of major complications, cardiovascular complications, and all-cause readmission rates. However vascular complications may be higher in transplant recipients. Further large-scale studies are needed to confirm these findings.

Periodic paralysis is a rare muscle disease that manifests as episodes of painless muscle weakness, and the hypokalemic form is commonly associated with hyperthyroidism. Most tachyarrhythmias related with thyrotoxicosis include sinus tachycardia and atrial fibrillation, but an association between thyrotoxic hypokalemic periodic paralysis and typical atrial flutter has seldomly been documented. Here, we present the case of a young male who was diagnosed with thyrotoxic periodic paralysis causing cavotricuspid isthmus-dependent atrial flutter, successfully treated with diltiazem, propranolol, methimazole, potassium iodine (SSK) and rivaroxaban.

Background & Aim Cardiogenic shock (CS) withholds a significantly high mortality rate between 40-60% despite advances in diagnosis and medical/surgical intervention. To-date, machine learning(ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROC) accuracy for the early prediction of CS. Methods A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards early detection of CS. Results A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N=21) evaluated patient outcomes, of which 14.3% (N=3) were assessed. The collective patient cohort (N=698) consisted of 314(45.0%) females, with an average age and body mass index (BMI) of 64.1years and 28.1kg/m2, respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (alfa=0.05), deeming it of superb sensitivity and specificity. Conclusions From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions prior to standardizing use of these technologies.

BACKGROUND AND AIM Cardiogenic shock (CS) withholds a significantly high mortality rate between 40% and 60% despite advances in diagnosis and medical/surgical intervention. To date, machine learning (ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROCs) accuracy for the early prediction of CS. METHODS A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed the accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards the early detection of CS. RESULTS A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N = 21) evaluated patient outcomes, of which 14.3% (N = 3) were assessed. The collective patient cohort (N = 698) consisted of 314 (45.0%) females, with an average age and body mass index of 64.1 years and 28.1 kg/m2 , respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (α = .05), deeming it of superb sensitivity and specificity. CONCLUSIONS From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions before standardizing the use of these technologies. BRIEF SUMMARY The catastrophic risk of developing CS continues to be a concern in the management of critical cardiac care. The use of ML predictive models have the potential to provide the accurate and necessary feedback for the early detection and proper management of CS. This systematic review summarizes the AUC-ROCs accuracy for the early prediction of CS.

Background: Marfan syndrome (MFS) is a connective tissue disorder that can lead to aortic disease, arrhythmias and heart failure. Many centers are reluctant to offer orthotopic heart transplantation (OHT) for patients with MFS with concurrent aortic disease due to complexity of the surgery and perceived inferior results when compared to patients without MFS. Methods: We present a case of a patient with MFS with previous Bentall procedure who underwent successful OHT, accompanied by a literature review on OHT performed for patients with MFS. Results and Conclusions: Patients with MFS who underwent OHT had no difference in mortality compared to patients without MFS. Even though OHT is technically more challenging when combined with concurrent intervention for aortic disease, it should be considered as a life-saving operation for patients with MFS.

Left atrial appendage occlusion has become a safe and effective alternative for stroke-risk reduction among patients with non-valvular atrial fibrillation (AF). Although complete closure is ideal, residual peri-device leaks (PDL) are not uncommon and have been associated with an increased residual risk of stroke. PDL closure has been proposed as an alternate strategy to allow for the safe discontinuation of oral anticoagulation. We describe the safety and feasibility of successful PDL closure using a non-fenestrated Cardioform (Gore Medical, Flagstaff, Arizona) septal occluder after initial Watchman (Boston Scientific, Marlborough, Massachusetts) implantation.

OBJECTIVE This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure. BACKGROUND The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. METHODS A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. RESULTS We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (

Pseudo thrombotic microangiopathy is a distinct clinical entity that is seen in patients with B12 deficiency. We describe a patient who presented with microangiopathic hemolytic anemia, thrombocytopenia, altered mentation and renal insufficiency. Thrombotic thrombocytopenic purpura was a major concern; however the peripheral blood smear showed hypersegmented neutrophils and the altered mental status as well as renal dysfunction improved with red cell transfusions. It was concluded that her clinical picture was more consistent with ineffective erythropoiesis, which can mimic thrombotic thrombocytopenic purpura (TTP). She was ultimately diagnosed with pernicious anemia based on positive intrinsic factor antibody, elevated methylmalonic acid, and homocysteine levels. Her B12 levels were falsely elevated which confounded the diagnosis. Distinguishing between these two conditions is imperative to avoid unwarranted plasmapheresis.

Introduction Fluctuations in hormonal levels can alter cardiac myocytes at the cellular level, often resulting in deterioration of cardiac function. Endocrine cardiomyopathies have been described in the setting of hypo/hyperthyroidism, GH deficiency, acromegaly, and diabetes. However, it is rarely described in the setting of autoimmune polyglandular syndrome (APS). Case Report A 19 year-old male with a PMH of APS associated with hypothyroidism and adrenal insufficiency. He initially presented to an outside facility after a syncopal episode. Initial workup revealed a TSH of 70 and he was started on appropriate therapy. Soon after admission, he developed acute hypoxemic respiratory failure requiring urgent intubation. Due to severe pulmonary edema, an echo was obtained which revealed a severely decreased EF of 20%. An Impella CP® and Swan Ganz catheter were placed for management of cardiogenic shock. Due to persistent clinical deterioration with worsening renal and hepatic function, he underwent RPella® placement. Two days later he was transferred to our hospital for consideration of advanced Heart Failure therapies. Upon transfer, he was maintained on appropriate hormone therapies by endocrinology. An endomyocardial biopsy was unrevealing. We started low dose diuretics and noted marked improvement in right sided parameters with improving central venous pressures and resolving transaminitis. Repeat echo revealed normal right ventricular systolic function. The RPella® was then weaned off and electively removed. The Impella CP® device was weaned daily as per protocol. EF improved to 30% on repeat echo. Cardiac MRI was nonspecific. He was downgraded from ICU status after tolerance of comprehensive guideline based medical therapy. Summary Previously described is a 32 year old male with a history of APS who developed severe biventricular failure requiring inotropic support, counterpulsation, mechanical circulatory support (MCS), and ultimately cardiac transplantation. Though our patient presented to us in a highly compromised state, the use of MCS helped bridge the patient to a recovery in myocardial performance while undergoing hormonal replacement. To our knowledge, this is the first case of its nature and highlights the possibility of temporary MCS in APS-associated cardiomyopathy, and in turn, can be useful in other secondary cardiomyopathies.

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

To date, only a few cases of coronary artery bypass graft (CABG) utilizing saphenous vein graft (SVG) from descending aorta to a native coronary vessel have been reported. We present a case of percutaneous intervention (PCI) involving SVG arising from descending aorta to left circumflex artery (LCx

Tricuspid valve (TV) endocarditis presenting as a pulmonary artery (PA) septic embolism is a rare but frequently fatal complication. Most septic pulmonary embolism (PE) occlude segmental or subsegmental PA. Large central septic PE is rare with only 4 such cases reported previously. There is lack of

A variety of semi-rigid, fenestrated, Amplatzer vascular plugs have been used percutaneously to seal paravalvular leaks (PVL) with meaningful success; however, incomplete closure and refractory hemolysis remains a common problem. A 76-year-old man with a history of redo open aortic and mitral valve

Introduction: Ventricular ectopy after exercise, due to parasympathetic activity, predicts an increased risk of death in population-based cohorts. We sought to examine the composite risk of all cause mortality in patients with premature ventricular contractions (PVCs) in the early recovery phase of stress testing. Methods: PubMed, Medline & EMBASE were queried for all English language articles from 1993 to 2017. The primary outcome was incidence of all cause mortality in patients with frequent PVCs during recovery phase (RPV) of stress testing. Frequent PVCs were defined as the presence of seven or more ventricular premature beats/min, frequent ventricular couplets, ventricular bigeminy or trigeminy, or any other form of ventricular tachycardia or ventricular fibrillation. Meta-analysis of the main outcome was performed using a weighted random effects model. Results: A total of four observational studies including 38765 patients were retrieved. Data for 2065 patients with RPV was pooled. A comparative analysis of PVC vs Infrequent/Non-PVC group showed a calculated risk ratio for all cause mortality of 1.8 (95% CI 1.36-2.38; p=0.001). I 2 statistic for heterogeneity testing was 82.8% (Fig.1). Conclusion: Frequent premature ventricular contractions during early recovery phase of stress testing are associated with increased all cause mortality as compared to patients with infrequent or no PVCs.

Background: There is a growing body of evidence against the use of triple therapy (anticoagulation and dual antiplatelet) among patients with acute coronary syndrome. Venous thromboembolism (VTE) is another potential indication for triple therapy, but the magnitude of such problem is unknown. Therefore, we aimed to determine the trends of annual rate of immediate VTE occurrence in patients with ST-segment elevation myocardial infarction (STEMI) and measure its impact. Methods: We queried the 2003-2013 Nationwide Inpatient Sample to identify adults with primary diagnosis of STEMI using ICD-9-CM codes. VTE, including limb vein thrombosis and pulmonary embolism, was allocated when present among the secondary discharge diagnosis. Demographics and inpatient outcomes were compared in the VTE and non-VTE group. Results: From 2,495,757 hospitalizations for STEMI, 15,471 (0.6%) also experienced VTE. The group who experienced VTE was older (mean age: 68.44 vs 64.81, p Conclusion: There is an increasing annual rate in immediate VTE occurrence in patients with STEMI. VTE is associated with more bleeding complications, longer hospital stay, and higher mortality. It is plausible that individualized or more aggressive protocols of VTE prophylaxis are needed in this population.

Stroke is a major cause of death and disability in the United States and underserved communities are at higher risk for complications, severity and recurrence of stroke compared to the general population. Atrial fibrillation (A-fib) predisposes to ischemic stroke occurrence; however, newly diagnosed A-fib at the time of stroke, and its predictive value in the outcome of underserved patients has not been reported. Aim: To explore the clinical significance of newly diagnosed A-fib among underserved populations with ischemic stroke. Methods: Retrospective cohort of patients with acute ischemic stroke diagnosis at John H. Stroger Hospital in 2014. New A-fib confirmed by electrocardiography. Stroke events were confirmed by magnetic resonance imaging or computed tomography. Given our small event rate we dichotomized National Institute of Health Stroke Scale (NIHSS) into severe (≥15) and non-severe ( Results: A total of 424 patients for the analysis, mean±SD age of 59.2±11.9 years, mostly male (57.5%), the majority African Americans (59.7%) followed by Hispanics (20.3%). The mean±SD follow up was 22.7±16.6 months, and 24 patients died (5.7%). A-fib was newly diagnosed in 8 (1.9%) patients and a third (37.5%) met indication or accepted anticoagulation. We adjusted for age, hypertension, diabetes, prior stroke, prior A-fib, anticoagulation, alcohol, smoking history and NIHSS. In our model NIHSS ≥15 was the strongest predictor or mortality (HR: 8.04; 95%CI: 2.14-30.25; p Conclusion: Our results are hypothesis generating, and suggest that ischemic stroke secondary to newly diagnosed A-fib carries worse overall survival. It’s plausible that this subset of patients may require a tailored longitudinal plan to reduce risk of poor outcomes in an undeserved population.

Gastrointestinal bleeding (GIB) is a well reported complication among patients admitted with acute ischemic stroke (AIS). However, literature regarding GIB in patients with AIS due to atrial fibrillation (AFIB) is lacking. A retrospective analysis using data from the national inpatient sample 2005