Risultati per: Case report: porpora di Schonlein-Henoch in una giovane adulta in ambulatorio di Medicina Generale

Circulation, Volume 150, Issue Suppl_1, Page A4144526-A4144526, November 12, 2024. Introduction:Immune checkpoint inhibitors (ICI), such as pembrolizumab, are an effective immunotherapy for several malignancies, however, have been associated with adverse events including myocarditis and accelerated atherosclerosis. ICI myocarditis is associated with a mortality rate of up to 33%. This case reports a patient on pembrolizumab with an atypical presentation.Case presentation:A 75-year-old female with a past medical history significant for lung cancer on pembrolizumab and myasthenia gravis presented to the hospital with dyspnea and mild, intermittent exertional chest discomfort. She denied nausea, radiation of pain, diplopia, weakness in extremities, or dysphagia. Workup revealed a leucocyte count of 13,500 cells/uL, pro-brain natriuretic peptide of 13,458 pg/mL, troponin of 26 ng/L, and a normal erythrocyte sedimentation rate and C reactive protein. A chest computed tomography was performed that showed mild bilateral pleural effusion and no pulmonary embolism. A nuclear stress test showed no evidence of ischemia but showed a severely reduced left ventricular ejection fraction (LVEF) at 29%. An echocardiogram confirmed that the ejection fraction was reduced at 23% (baseline LVEF was 60% from 1 year ago). Cardiac MRI revealed a mildly increased regional T2 signal in the anterolateral wall, mildly elevated extracellular volume fraction, and no late gadolinium enhancement. With ongoing clinical suspicion despite equivocal findings on cardiac MRI, an endomyocardial biopsy was done that revealed a single small aggregate of lymphocytes present in 1 of 6 tissue samples. Ultimately, with the single site of aggregated lymphocytes on biopsy, a diagnosis of ICI myocarditis was determined, and the patient was started on high-dose intravenous glucocorticoids as well as bisoprolol, empagliflozin, spironolactone, and Entresto for heart failure management as she was able to tolerate.Discussion:Myocarditis due to pembrolizumab is a rare, but potentially lethal adverse effect. Patients typically have abnormal electrocardiograms and elevated cardiac biomarkers. Cardiac MRIs have sensitivity and specificity of 68% and 91% respectively for diagnosis, and the gold standard is endomyocardial biopsy however, it is limited due to sampling error. Our patient had an unusual presentation, but with both imaging and biopsy, we found a case of focal myocarditis with severe left ventricular dysfunction, which typically is seen with fulminant myocarditis.

Circulation, Volume 150, Issue Suppl_1, Page A4143264-A4143264, November 12, 2024. Background:R-on-T phenomenon occurs when an electrical stimulus is delivered at a critical point during ventricular repolarization. This can initiate ventricular arrhythmias like polymorphic ventricular tachycardia (PMVT). We describe a case of ventricular pacemaker spikes delivered on the T wave causing PMVT.Case:A 53-year-old female with CAD s/p stent, postpartum cardiomyopathy s/p Bi-V CRT-D (Boston Scientific G124), and paroxysmal atrial fibrillation presented for elective endoscopy and colonoscopy to evaluate her dysphagia and abdominal pain. Her CRT-D was reprogrammed from DDD pacing with lower rate limit (LRL) 50 bpm to an asynchronous Bi-V DOO mode at 50 bpm (‘electrocautery mode’) for the procedure (tachy therapy disabled). Her LV-RV offset was 40 msec. Prior to receiving sedation or medications, she was found unresponsive. Telemetry showed Spike-on-T phenomenon which initiated PMVT. She was externally defibrillated with 200J and received magnesium and an IV amiodarone bolus. She returned to sinus rhythm, but one minute later had another Spike-on-T event initiating PMVT. She was successfully defibrillated with 360J. Post-shock EKG showed an asynchronous Bi-V paced rhythm at 50 bpm.Decision Making:The patient was admitted to the CCU for post-resuscitation care. Her electrolytes and cardiac enzymes were unremarkable. Her CRT-D was reprogrammed to DDD 80-140 bpm. Transthoracic echocardiogram showed normal biventricular systolic function. Cardiac catheterization did not show obstructive CAD. After reprogramming of her device, she had no further events. After initial treatment with IV amiodarone load, she was discharged home on oral magnesium gluconate.Discussion:The only intervention prior to her procedure was device reprogramming (DDD 50 bpm to DOO 50 bpm). Telemetry showed pacer spikes initiating PMVT. Given the LV-RV offset of 40 msec, she would have received these two tightly coupled pacemaker spikes in an asynchronous mode, in this unfortunate instance during her T wave. While her bowel preparation may have led to electrolytes abnormalities, post-resuscitation electrolytes were normal. Fortunately, she received prompt therapy and was reprogrammed with increased LRL.Conclusion:We described a case of Spike-on-T PMVT prior to colonoscopy without obvious provocation other than asynchronous pacemaker spikes. Reprogramming devices in DOO mode with increased LRL may prevent PVCs and asynchronous pacemaker spikes from triggering PMVT.

Circulation, Volume 150, Issue Suppl_1, Page A4145899-A4145899, November 12, 2024. Introduction:Premature Ventricular Contractions (PVCs) are often a benign arrhythmia. However, those originating from the Purkinje system can result in fatal arrhythmias. One example is PVCs originating from the moderator band (MB) within the right ventricle (RV) of the heart. We present a case of PVCs originating from the MB triggering idiopathic ventricular fibrillation (VF) and electrical storm.Case:A previously healthy 49-year-old woman was admitted following a witnessed VF cardiac arrest. She had recurrent episodes of VF, initially treated with Amiodarone and Procainamide which failed to suppress the recurrent VF. She received 54 external defibrillations before a transvenous pacer (TVP) was placed to override the PVCs at a pacing rate of 110 bpm. Post-resuscitation ECGs revealed frequent PVCs originating from the RV free wall, potentially from the lateral part of MB (Figure 1). Quinidine was added to suppress the PVCs ultimately allowing removal of the TVP. Transthoracic Echocardiogram revealed normal cardiac function and a prominent MB. A cardiac MRI was performed showing no infiltrative disease or any other abnormalities. The patient underwent sympathectomy and defibrillator placement. Despite recurrent cardiac arrest, she had excellent neurologic recovery and was subsequently discharged on Quinidine.Discussion:MB extends from the septal wall to the base of the anterior papillary muscle in the RV, carrying Purkinje fibers(PF) from the right bundle branch as it exits the septum. Purkinje fibers have been shown to initiate arrhythmias by several mechanisms including enhanced automaticity, triggered activity and re-entry. In the genesis of PVCs, triggered activity is the likely mechanism. This can degenerate into VF in a structurally normal heart, hence the term “idiopathic VF”. Familiarity with this entity and ECG features of MB ectopy leads to timely management and may potentially prevent lethal arrhythmias in symptomatic patients with such PVCs. Further studies are required to fully understand the arrhythmogenic mechanisms and the optimal management approach for MB ectopy.

Circulation, Volume 150, Issue Suppl_1, Page A4135629-A4135629, November 12, 2024. Background:Regular physical activity provides numerous health benefits including improved cardiovascular health. Population-level physical activity surveillance is critical for informing research, practice, and policy efforts for supporting population health and health disparities. The United States Report Card on Physical Activity for Children and Youth addresses physical activity surveillance needs by integrating data from numerous sources capturing levels of physical activity and related behaviors (e.g., sedentary behavior, sleep), and facilitators and barriers for physical activity among United States youth. The 2024 Report Card is the 5thand decennial iteration in the series, released October 2024.Methods:A Report Card Working Group was assembled under the auspices of the Physical Activity Alliance and National Physical Activity Plan. Members reviewed the evidence for 11 indicators using data from nationally representative surveys and assigned grades. Data were examined for the overall population and, when possible, by age, sex, race/ethnicity, and disability subgroups. A standardized grading rubric was used to assign a letter grade to each indicator ranging from A to F. Trends in key benchmarks over time were examined since the first report card (2014) or earliest available data.Results:Sufficient data were available to assign grades for 8 of the 11 indicators. The assigned grades ranged from B- to F, with overall physical activity levels earning a D- (Table 1). No indicators improved since 2014. Five indicators – overall physical activity, organized sport participation, active transportation, sedentary behaviors, and school – worsened since 2014.Conclusions:The compiled surveillance report indicates generally poor grades and concerning trends over the recent decade. These findings highlight opportunities to improve physical activity levels and resources for supporting cardiovascular health among United States youth. Policy approaches are needed to combat societal factors that interfere with physical activity. Gaps in data availability, specificity, and quality point to needs for improved surveillance to track impacts. The 2024 Report Card can be a tool for supporting advocacy of regular physical activity at the national and local level.

Circulation, Volume 150, Issue Suppl_1, Page A4148074-A4148074, November 12, 2024. Introduction/Background:Transradial cardiac catheterization (TRC) is recommended for patients with acute coronary syndrome over femoral artery catheterization. Randomized controlled trials show TRC has significantly lower rates of bleeding, vascular complications, and mortality in high-risk acute coronary syndrome patients. However, vascular complications like radial artery spasm, occlusion, arteriovenous fistula, perforation, and pseudoaneurysm (PSA) can still occur. Despite TRC’s widespread adoption, recent data summarizing radial artery pseudoaneurysm post-TRC is lacking.Research Question/HypothesisThis review aims to identify at-risk patients, present a case of catheterization-related radial artery pseudoaneurysm, and provide diagnostic and management insights. We hypothesize that older patients with hypertension are at higher risk and that early detection and management are associated with low complication rates.Methods/Approach:Systematic searches were conducted in PubMed, Web of Science, EMBASE, and CINAHL databases. Two researchers independently selected articles, extracted data, and evaluated study quality on RA PSA post-TRC (2003–2023). A third reviewer resolved conflicts. The Joanna Briggs Institute (JBI) tool was used to evaluate bias risk. Additionally, a case report is presented.Results:From 3,262 records, 43 studies were selected, involving 67 patients (58.8% female, median age 73.5 years). Hypertension (39.5%) and atrial fibrillation (27.9%) were the most common comorbidities. Percutaneous interventions like stenting and angioplasty caused 58.1% of cases; diagnostic catheterizations accounted for 37.2%. Ultrasonography diagnosed 83.7% of cases. Symptoms appeared a few hours to four months post-TRC, with pulsatile mass (21.4%) and swelling (14.3%) being the most common, and pain and ecchymosis at 2.4% each. More than half of the patients (51.2%) required surgical intervention, but 66.7% recovered without deficits. Severe complications were rare, affecting fewer than 5%.Conclusions:A literature review of 43 articles with 67 patients suggests older female patients with hypertension may be more prone to radial artery pseudoaneurysm post-TRC. It typically presents as a pulsatile, painful swelling detectable by ultrasound. This complication precludes the use of the radial artery as a conduit for coronary artery bypass grafting. The review highlights the importance of vigilant post-catheterization monitoring to enable early detection and treatment.

Circulation, Volume 150, Issue Suppl_1, Page A4120854-A4120854, November 12, 2024. Introduction:Familial hyper-alpha-lipoproteinemia (HALP) is a heterogenous genetic lipid disorder that is found in only 8% of the population and manifests as elevated HDL levels above the 90thpercentile. HALP is due to mutations in various genes including cholesteryl ester transfer protein (CETP), hepatic lipase, or apolipoprotein C-III (APOC3). While epidemiological studies have noted an inverse relationship between high HDL and the development of coronary artery disease, recent data have shown a lack of causal atheroprotective effects. We present a case of a patient with significantly elevated HDL and peripheral vascular disease.Case Description:Patient is a 64-year-old female with past medical history of peripheral artery disease with occlusion of the left femoral artery and popliteal arteries status post angioplasty, hypertension, type 2 diabetes, alcohol use, and CKD Stage 4 who presented to the advanced lipid clinic for management of elevated lipoproteins. Patient’s laboratory data was significant for total cholesterol (TC) of 375 mg/dL, a high-density lipoprotein (HDL) of >200 mg/dL, triglycerides (TG) of 66 mg/dL, and a low-density lipoprotein (LDL) of 175 mg/dL. Further testing revealed elevated apolipoprotein A-I of 231 mg/dL. Patient was subsequently initiated on a high intensity statin with improvement in her lipid panel with a TC of 247 mg/dL, HDL of 133 mg/dL, TG of 50 mg/dL, and LDL of 106 mg/dL, with plan for further uptitration of lipid therapy to target LDL

Circulation, Volume 150, Issue Suppl_1, Page A4142117-A4142117, November 12, 2024. Introduction:The management of patients with Venous thromboembolism (VTE) receiving anticoagulant therapy is complicated by potential interactions with other medications, including antibiotics. Piperacillin-tazobactam (PTZ) has been implicated in unexpected disturbances in the coagulation cascade, which can be critical in patients concurrently using anticoagulants like rivaroxaban. This report explores the complexities of prescribing broad-spectrum antibiotics to patients with pre-existing cardiac conditions and the necessity of careful consideration of drug-drug interactions.Case Report:A 52-year-old white male with a history of deep vein thrombosis on rivaroxaban, presented with severe left leg cellulitis and subsequent gastrointestinal bleeding shortly after the initiation of piperacillin-tazobactam. His presentation was complicated by a rapid deterioration in his condition following a syncopal episode, characterized by hematochezia and hematemesis, necessitating urgent medical interventions including the cessation of all anticoagulation therapy, esophagogastroduodenoscopy and broad-spectrum antibiotics.Discussion:This case highlights the clinical challenges and potential risks of coagulopathies induced by PTZ or the interaction of PTZ with rivaroxaban, stressing the importance of multidisciplinary vigilance. The mechanisms by which PTZ may influence the coagulation pathways in patients already at risk due to their cardiac profiles underscore a significant area of concern for clinicians.

Circulation, Volume 150, Issue Suppl_1, Page A4142149-A4142149, November 12, 2024. Background:As patients progress through the single ventricle palliation, changing hemodynamics and non-cardiac conditions can prevent completion of Fontan. We sought to determine the incidence of completion of Fontan at our institution and to investigate the reasons for non-Fontan candidacy.Methods:Institutional database was queried to identify patients who underwent single ventricle palliation from 2010 to 2020. Patients who underwent stage 2 palliation were included for analysis. The primary outcome of interest was reason for non-Fontan candidacy or reason for delayed Fontan.Results:526 patients who reached stage 2 single ventricle palliation were analyzed. 378 (71.9%) underwent Fontan procedure or were referred for Fontan before the age of 4-years-old at our center at the time of the study (Figure 1). 19 patients died prior to the typical age of Fontan and 38 were lost to follow up. Of the remaining 91 patients, 21 (23.1%) had a 1.5 or 2 ventricle repair, 12 (13.2%) had a Fontan at another center, and 29 (32%) had a late Fontan. Most patients with late Fontan were due to provider practice variation (22), whereas there were only 3 patients with medical conditions delaying pre-Fontan testing, and 4 patients had a Kawashima. Only 3 patients out of the 12 who had Fontan at another center were for second opinions, whereas the remainder either moved or had surgery at another center due to family preference. Reasons for non-Fontan candidacy were divided into cardiac and respiratory sources. Cardiac reasons included severely depressed ventricular function (12), diastolic dysfunction (2), atrioventricular valve stenosis or regurgitation (7), and pulmonary vein stenosis (3). Respiratory conditions leading to non-Fontan candidacy included severe OSA (1), pulmonary arterial malformation (1), and pneumonectomy (2). There are 17 patients in the non-candidacy group who had a heart transplant or were listed for transplant at the time of the study. No patient in our study was deemed not a candidate for Fontan after stage 2 palliation for developmental delay or syndrome.Discussion:This study demonstrates that the reasons for non-Fontan candidacy after completion of stage 2 palliation are broadly due to hemodynamic and respiratory condition, with many patients who are not candidates developing severe ventricular dysfunction after stage 2. There is a subset of patients who either move, are lost to follow up, or are delayed due to provider practice variation.

Circulation, Volume 150, Issue Suppl_1, Page A4145273-A4145273, November 12, 2024. Background:Extraction of unstructured and semi-structured medical data is a key prerequisite for the application of bioinformatics. Portability, scalability, and protection of health information remain key problems in data analytics in medicine that cannot easily be solved using machine learning techniques alone, highlighting the importance of multi-faceted approaches.Research Question / Hypothesis:Can rule-based algorithms reliably and identify and extract transthoracic echocardiographic (TTE) report findings for use in a data analytics pipeline?Methods:Deidentified adult TTE reports were obtained between 09/14/2020 to 03/30/2023 within a single urban academic healthcare system. A rule-based algorithm was developed using derivatives of regular expressions in R to capture chamber parameters, cardiac function, and valvular disease. The accuracy was evaluated in a subset of manually adjudicated reports by study cardiologists.Results:Of the 1000 reports obtained, we were able to extract 23079 (78.4%) populated data points out of 29423 maximal data points for 37 variables. Out of 803 manually verified NA data points, 743 (92.5%) were accurate. The mean net accuracy of all variables was 99.8% (see Table 1). Continuous data points showed 100% accuracy. Modes of failure for data extraction were in categorical variables (7.5% of the 23 features), with the most common being in left atrial size (n=6), mitral valve structure (n=5), aortic valve structure (n=13), tricuspid valve structure (n=2) and right ventricular function (n= 7). All other categorical variables showed 93.6% mean accuracy of NA data points.Conclusions:A rule-based algorithm is effective at converting cardiologist-read TTE reports into datasets ready for use data analytics. Moving forward, it would be important to test this tool on metrics of speed, cluster computing and scalability.

Circulation, Volume 150, Issue Suppl_1, Page A4112944-A4112944, November 12, 2024. Case:A 62-year old male with a history of chronic kidney disease and paroxysmal atrial fibrillation presented with several months of fatigue, a progressive decline in functional status (NYHA IIIb-IV), weight loss, and intermittent lower extremity swelling. Blood pressure was 92/72 mmHg on presentation, and heart rate was 90 bpm. Physical examination revealed a jugular venous pressure of 12-14 cm H2O and 2+ bilateral lower extremity edema with mild wheezing.Methods/workup:Laboratories are shown in Table 1 and were notable for a serum free light chain ratio of 0.14. Transthoracic echocardiogram (figure 1) revealed a left ventricular (LV) ejection fraction of 33% with increased LV wall thickness and severe bi-atrial enlargement. Bone marrow biopsy revealed 2% lambda restricted plasma cells without evidence of amyloid deposits; metastatic bone survey was negative. A fat pad biopsy and endomyocardial biopsy stained negative for amyloid with Congo red. Cardiac MRI showed diffuse, circumferential subendocardial late gadolinium enhancement, most compatible with cardiac amyloidosis (figure 2). The patient also had a chest CT scan that demonstrated a few patchy nodular pulmonary infiltrates. Given his extensive negative workup, he was referred to pulmonary and endobronchial biopsy was positive for amyloid on Congo red staining (figure 3). Biopsy tissue typing revealed Lambda subtype AL amyloidosis.Management:The patient was started on Daratumumab, Cyclophosphamide, Bortezomib, and Dexamethasone by Hematology. Unfortunately, about a month after his diagnosis, he developed worsening heart failure despite treatment. He was admitted to an outside hospital with refractory cardiogenic shock and passed away during that admission.Discussion:The diagnosis of AL amyloidosis requires a high index of suspicion for prompt diagnosis and treatment. We present a case in which cardiac amyloidosis was suspected based on the patient’s clinical picture and cardiac imaging; however, multiple initial biopsies were negative. An expedited, multimodal and interdisciplinary diagnostic assessment is imperative as prognosis with chemotherapy is highly dependent on extent of AL disease, patient functional status, and presence of cardiac compromise. Elevated natriuretic peptides, troponins, autonomic dysfunction, and hypotension are negative prognostic features.

Circulation, Volume 150, Issue Suppl_1, Page A4145408-A4145408, November 12, 2024. Background:Stress cardiomyopathy (SCM) is rarely triggered by ketamine and seldom leads to cardiogenic shock. Ketamine-induced catecholaminergic surge can lead to myocardial stunning with transient ischemia and subsequent reversible heart failure. Mechanical circulatory support can be successfully leveraged in SCM-associated cardiogenic shock while awaiting myocardial recovery.Case Presentation:A 28-year-old female with chronic pain was admitted for failure to thrive secondary to opioid-induced gastroparesis. The patient was weaned off opiates while on ketamine over 4 days. After halting ketamine, the patient had a cardiac arrest with eventual return of spontaneous circulation. After being extubated, she developed chest pain, hypotension, and ventricular tachycardia with anterolateral ST elevations, troponin leak, and lactic acidosis. TTE revealed an EF

Circulation, Volume 150, Issue Suppl_1, Page A4137805-A4137805, November 12, 2024. Background:Many of the 1.4 million adults with congenital heart disease (CHD) are lost to follow up (LTF). We aimed to identify factors associated with LTF and compare to those who remained in care.Methods:In the Congenital Heart Disease Project to Understand Lifelong Survivor Experience (CHD PULSE), we performed a cross-sectional survey in 2021-2023 of CHD survivors with a history of intervention at 11 centers in the Pediatric Cardiac Care Consortium, a large US-based registry of CHD procedures. Participants reported their cardiac history, general health, education, income, health insurance, healthcare utilization, and marital status. LTF was defined as having seen a cardiologist three or more years ago.Results:Among the 3109 respondents with CHD (median age 33) there were 1157 (37%) LTF and 1952 (63%) in care. Age, sex, marital status, and household income were not risk factors for LTF; but lack of health insurance, lower severity of CHD, and increasing time since last heart surgery were. Notably, respondents who reported being told in adolescence about the lifelong need for a cardiologist were almost three times as likely to report being in care (79% vs 28%, p

Circulation, Volume 150, Issue Suppl_1, Page ASa304-ASa304, November 12, 2024. Background:Since January 2022, our emergency medical center has operated a prehospital extracorporeal cardiopulmonary resuscitation (ECPR) system. The ECPR team is dispatched for suspected CPA cases. Criteria for ECPR on the scene include patients aged 65 or younger with an initial rhythm of shockable or PEA. Additionally, witness presence, bystander CPR, and blood gas analysis are considered. Due to the difficulty in obtaining accurate on-scene information, the Sign of Life (SOL) is crucial. Cannulation is performed in a mobile ICU under mechanical CPR, with ultrasound-guided cannulation as the first choice. Once ECMO is established, systemic O2/CO2 optimization using a gas blender and rapid initiation of targeted temperature management (TTM) at 34°C are performed. This is the only system in Japan systematically performing prehospital ECPR for all OHCA cases, known as the “Utsunomiya model.”Objective:To evaluate the outcomes and feasibility of prehospital ECPR at our facility in Japan.Methods:This retrospective case series included patients who underwent prehospital ECPR between January 2022 and May 2024. The primary outcome was favorable neurological outcome, and secondary outcomes included 28-day survival and complications.Results:The prehospital ECPR system responded to 113 calls, resulting in 14 cases where ECPR was performed (11 identified as CPA by dispatchers, and 3 as non-CPA). The average patient age was 59 years, 85.7% were male, 64.3% had witnessed arrests, and bystander CPR was performed in 71.4% of cases. SOL was present in 57.1%, with initial rhythms: shockable in 28.6%, PEA in 50%, and asystole in 21.4%. ECMO-related metrics included a no-flow time of 2.5 minutes and a low-flow time of 33 minutes. Cannulation was performed percutaneously under ultrasound guidance, with an average cannulation time of 9.5 minutes. Favorable neurological outcomes were achieved in 28.6% of cases, with a 28-day survival rate of 64.3% and a complication rate of 0%. Among cases with SOL, the 28-day survival rate was 87.5%, and favorable neurological outcomes were 50%. Of the four cases with favorable outcomes, one had a shockable rhythm, two had PEA, and one had asystole, all with SOL.Conclusion:Prehospital ECPR is a feasible intervention within the Japanese emergency medical system, demonstrating promising outcomes. Further studies are required to optimize patient selection and procedural protocols to improve results.

Circulation, Volume 150, Issue Suppl_1, Page A4139373-A4139373, November 12, 2024. Introduction:Takotsubo cardiomyopathy (TCM) is a transient condition characterized by left ventricular dysfunction, often triggered by stress, although its exact pathogenesis remains unclear. We are presenting a case of TCM triggered by an acute manic episode, shedding light on the interplay between psychological states and cardiac function. Additionally, this case underscores the heightened risk of QT prolongation and ventricular fibrillation associated with antipsychotic medications.Case Description:A 32-year-old female with a history of bipolar I disorder was admitted to the psychiatric unit for an acute manic episode and was immediately started on Olanzapine. On the second day of admission, the patient collapsed and was found to be in ventricular fibrillation. After three cycles of cardiopulmonary resuscitation and two direct current shocks, the patient achieved a return of spontaneous circulation and sinus rhythm. She was intubated and transferred to the ICU, where an EKG revealed a QTc of 497 ms (Figure.2). A follow-up EKG after 12 hours showed dynamic T-wave inversions and a prolonged QTc of 615 ms (Figure.1). Echocardiography indicated apical akinesis with severely decreased systolic function, with an ejection fraction of 30%. CT coronary angiography was normal. The patient was diagnosed with Takotsubo cardiomyopathy and started on metoprolol. On the fourth day of admission, an automatic implantable cardioverter-defibrillator was implanted. At six-month follow-up, the patient’s EKG showed a normal QTc of 420 ms (Figure. 2), and echocardiography demonstrated an improved ejection fraction of 55%.Conclusion:This case supports the hypothesis of catecholamine-induced myocardial stunning as a primary mechanism of TCM, illustrated here in the context of acute mania. Physicians should consider TCM as a potential complication of acute mania. Screening EKGs in patients experiencing manic episodes could be beneficial. If abnormalities are detected, serial EKGs, echocardiography, and medication adjustments may help prevent this potentially fatal consequence of acute mania. Although Olanzapine is not strongly linked to QTc prolongation compared to some other atypical antipsychotics, diligent electrocardiographic monitoring and close observation for any QTc prolongation are crucial. These measures play a pivotal role in preventing potentially fatal consequences associated with cardiac arrhythmias.

Circulation, Volume 150, Issue Suppl_1, Page A4139380-A4139380, November 12, 2024. Background:Imaging of conventional PM’s and ICDs are infrequently performed via MRI. While many studies, including theMagnaSafeTrialhave unequivocally supported MRI safety in patients with such devices, theaddedclinical value has rarely been considered. Accordingly, we performed an observational, IRB-approved, prospective study to determine the ‘Additive Value’beyondsafety for patients with conventional PM/ICD’s undergoing clinical MRI.Wehypothesizethat MRI in PM/ICD patients is critical to an existing diagnosis and often markedly alters diagnosis and subsequent downstream patient management.Methods:An MRI Device exam (GE 1.5T,WI) pioneered by cardiologists ( >90% over 10 yrs; 100% over 20 years) was performed. Subsequently, a series of prospective defining questions using Boolean Logic Construct were answered within 1 week of MRI by both MRI technologist and MRI physicians.Questions:1) Did the primary diagnosis change?2) Did the MRI provide additional information to existing diagnosis?3) Was the pre-MRI (tentative) diagnosis confirmed?4) Did subsequent patient management change?If ‘Yes’ was answered to any of the above questions, it was considered that MRI was of value to pt diagnosis and/or impending therapy.Results:Average MRI: 25±14min for 2,008 consecutive patients of which 1,526 (76%) were neuro/neurosurgery, 141 (7%) were musculoskeletal and 341(17%) were CV cases. Upon review: of the Neuro/neurosurgeryMRIs, 1,376 (89%) provided additional information.The diagnosis changed in 1018 (74%), while medical therapy changed in 977 (71%). In only 124 (9%) did MRI simply confirm original diagnosis. ForCardiacpatients, MRI changed the original diagnosis in 235 (69%). MRI did not contribute in 42 (12%) as it was uninterpretable (ICD artifact), while in 64 pts, the diagnosis did not change. Finally, in 146Orthopedicpts, MRI provided additional information in 143 (98%) and in 130 (89%), changed pt care, and in 4 pts (3%), simply confirmed the diagnosis. Importantly, with careful attention to device reprogramming and scanner sequences, no safety or device issues were encountered in any patient all with tracking for >1 year.Conclusion:Via a dedicated program of MRI in PM/ICD patients adds substantial clinical value to diagnosis and subsequent management justifying ant inherent risk(s). Herein, we propose that yet another impediment to the advancement of CMR-PM/ICD strategies can become routine and often life-changing.

Circulation, Volume 150, Issue Suppl_1, Page A4147765-A4147765, November 12, 2024. Case Description:A 74-year-old male with hypertension, hyperlipidemia, coronary artery disease status post PCI, paroxysmal atrial fibrillation, and coronary vasospasm presented with recurrent episodes of chest pain at rest described as substernal, pressure like, 10/10 lasting for a few minutes. The patient was hemodynamically stable upon presentation but had an event of pulseless ventricular tachycardia (VT) requiring shock x 2 (Image 1). The patient was stabilized, and an emergent left heart catheterization showed stable obstructive CAD with diffuse coronary vasospasm responsive to intracoronary nitrates (Image 2). The patient was transferred to the intensive care unit for further management. He had multiple prior presentations for chest pain, with one complicated by a transient hemodynamically unstable high grade AV block (Image 1). Prior work up was also consistent with coronary vasospasm despite being optimally managed on nitrates and calcium channel blockers. Despite medical management the patient had a refractory course with recurrent symptoms.Clinical Decision Making:As it was believed that symptoms were likely driven by high sympathetic tone, the patient was intubated and sedated for sympathetic drive suppression. After a multidisciplinary meeting with cardiothoracic surgery and electrophysiology, a decision was made to go for video assisted thoracoscopic surgery (VATS) which was performed successfully. The patient was extubated, had no recurrence of symptoms after, and was offered an implantable-cardioverter defibrillator at discharge for secondary prevention.Discussion:Coronary vasospasm can be life threatening due to transient and acute ischemia driven myocardial injury or arrhythmias. This case highlights the role of VATS sympathectomy in managing severe cases of vasospastic angina that are unresponsive to conventional treatments. Further studies are required to establish the efficacy and safety of this procedure in broader patient populations.