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.
Risultati per: La gestione del paziente depresso da parte del medico di medicina generale: case reports
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Abstract 4143142: Lost to Follow Up: A Rare Case of Malonyl-CoA Decarboxylase Deficiency Induced Cardiomyopathy in an Adult Spanish Speaking Hispanic Male
Circulation, Volume 150, Issue Suppl_1, Page A4143142-A4143142, November 12, 2024. Introduction:Malonyl-CoA decarboxylase deficiency (MLYCDD) is a rare inherited metabolic disorder with multi-organ involvement, causing cognitive impairment, cardiomyopathy, seizures, hypotonia, and acidosis. Variants in MLYCCD, the gene for malonyl-CoA decarboxylase, disrupt long chain fatty acid synthesis in cardiac tissue. Prevalence is estimated to be less than 1 in 1,000,000, with cardiomyopathy being the leading cause of morbidity and mortality. Less than 40 cases have been documented, the majority of which detail newborns. No guidelines exist for treatment. A high-carbohydrate, low-fat diet, and levocarnitine reportedly improve cardiac function.Presentation:A 30-year-old Spanish-speaking male with MLYCDD, with resultant heart failure with reduced ejection fraction (EF) and cognitive delay, presented to a community hospital with malaise. He was diagnosed at age 9 and followed with an interdisciplinary team, receiving care in Spanish and English since diagnosis. His treatment consisted of levocarnitine and dietary restrictions that had led to cardiac recovery. At 24, his doctor retired, his insurance changed, and he was lost to follow-up, leading to dietary liberalization. On presentation, he was diagnosed with pneumonia complicated by atrial fibrillation (AF). AF was treated with a diltiazem infusion, resulting in cardiogenic shock with an EF of 15% from 39%. He was transferred to an academic center where diltiazem was stopped, inotropes started, and impella placed. He started enteral nutrition with liquid protein, dextrose infusion, medium-chain triglyceride (MCT) oil, and levocarnitine, along with supportive care for pneumonia. Given persistent shock he was transferred to our center for advanced therapies evaluation. Notable changes included replacing MCT oil with triheptanoin and stopping the dextrose infusion. A repeat echocardiogram showed recovery of EF to 40%Conclusions:MLYCDD exhibits a range of phenotypes, with limited data on long-term outcomes. This presentation is atypical: an adult with cardiomyopathy diagnosed in adolescence, successfully treated, who decompensated after stopping a modified diet in the setting of pneumonia and diltiazem. This case offers several clinical insights: (1) Restrictive diets with levocarnitine supplementation are instrumental in treating MLYCDD. (2) Avoid diltiazem in heart failure to prevent iatrogenic shock. (3) Language-concordant care ensures patients understanding and supports seamless care transitions.
Abstract 4145267: An Unusual Case of Listeria LVAD Infection Complicated by Intracranial Catastrophe
Circulation, Volume 150, Issue Suppl_1, Page A4145267-A4145267, November 12, 2024. Description of Case:A 56-year-old male with ischemic cardiomyopathy, HeartMate 3 LVAD implantation presented with fatigue and diarrhea after eating expired cheese a week prior. Hypovolemia, AKI, an unremarkable LVAD interrogation and an INR of 3.4 were noted. Blood cultures and infectious work-up including imaging were obtained. Imaging was unremarkable. Over the first 2 hospital days, he was fluid resuscitated. Hemodynamics showed low biventricular filling pressures and adequate cardiac index. On hospital day 3, blood cultures revealedListeria monocytogenesprompting initiation of IV ampicillin. AKI worsened, associated with altered mentation requiring endotracheal intubation and renal replacement therapy.On hospital day 8, bronchoscopy was performed to address worsening respiratory secretions. An hour after procedural sedation, he never regained consciousness and anisocoria was noted. Emergent cranial imaging revealed multicompartment hemorrhage with midline shift. Neurosurgical intervention was not recommended due to the catastrophic nature of the bleeding. Supportive pharmacologic measures were futile; brain death was declared 48 hours later.Discussion:Listeria monocytogenesis a gram-positive rod which causes gastrointestinal illness in immunocompetent adults. Cases of Listeria bacteremia in patients with indwelling cardiac hardware are rare but have been previously described in the literature. A case ofListeriabacteremia and leukocytoclastic vasculitis in an LVAD patient resulting in AKI has been reported. To our knowledge, this is the first published case ofListeriabacteremia in an LVAD patient complicated by acute intracranial hemorrhage.While the exact mechanism of the brain bleed was not confirmed, it is postulated that the altered mental status and AKI were the products of septic embolization to the brain and kidneys, with ultimate hemorrhagic conversion noted in the setting of therapeutic anticoagulation. A transesophageal echocardiogram had been planned prior to the stroke but not performed due to medical futility.Clinicians should be aware of the more unusual complications ofListeriainfection in the setting of indwelling cardiac hardware.
Abstract 4144743: From Tummy Trouble to Heart Hassle: A Case of Traveler's Diarrhea Triggering Myopericarditis
Circulation, Volume 150, Issue Suppl_1, Page A4144743-A4144743, November 12, 2024. Case description: >A 38-year-old male with a history of paroxysmal atrial fibrillation status post-RFA ablation, presented to the emergency department (ED) with a 3-week history of non-bloody diarrhea, abdominal cramping, nausea, fever, and headache after a trip to Guatemala. In the ED, his vital signs were temperature (99.3 °F), and heart rate (116 bpm). Notable physical exam findings were diffuse erythematous macular rash and conjunctival injection. Initial labs demonstrated elevated white count (15,100 K/mcL) and lactate (3.2 mmol/L). He was treated with ceftriaxone and metronidazole, with clinical improvement. Stool cultures were positive for salmonella and cyclospora cayetanensis. On hospital day 3, he developed severe substernal chest pain, minimal ST elevation in the anterolateral leads on ECG and elevated HS- troponin levels of 7000 ng/ml, peak of 12000 ng/ml. Transthoracic echocardiogram showed normal LV systolic function, with no evidence of pericardial effusion and regional wall motion abnormalities. Subsequent cardiac MRI demonstrated evidence of myopericarditis(anterior and lateral pericardial enhancement, along with focal epicardial late gadolinium enhancement in the mid inferolateral wall of the left ventricle with associated myocardial edema, and a small pericardial effusion). He was discharged home on Trimethoprim-Sulfamethoxazole and started on colchicine, with no recurrent chest pain.Discussion:Myopericarditis is a complication of acute pericarditis due to pericardial inflammation extension to the myocardium. It is usually caused by a virus and rarely due to bacteria as demonstrated by this case, presenting as elevated troponin levels and ST-segment elevation on ECG. To our knowledge, there are no known reports of cyclospora cayetanensis causing myopericarditis. The adherence of the salmonella bacteria to the cardiac endothelium can result in myocyte necrosis and release of self-antigens leading to the development of antibodies and autoimmune myocarditis. Long-term management of bacterial myopericarditis is dependent on the severity of the clinical presentation and includes antibiotics, anti-inflammatory medications, and colchicine. Most patients recover within one month, but persistent cardiac dysfunction and progression to end-stage dilated cardiomyopathy can occur, thus follow-up echocardiography is recommended.
Abstract 4146424: Evaluating reported ethnicity, genetic ancestry and three-way local-ancestry admixture with preeclampsia in GenPE, a multi-center case-control study of Colombian women
Circulation, Volume 150, Issue Suppl_1, Page A4146424-A4146424, November 12, 2024. The role of genetic ancestry (GA) in hypertensive pregnancy disorders in Latin-American women is poorly understood.Using data from amulti-center case-control study (GenPE) of preeclampsia (PE) in young Colombian women(median age = 19) of predominantly low socioeconomic status (2364 controls and 1811 cases), who identify as Afro-Caribbean (AFR-C), White Hispanic (HISP), Amerindian, and Mixed ethnicity,we evaluated associations between 1) reported ethnicity, and 2) empirically estimated GA, with PE. We performed 3-way admixture mapping using European (EUR), African (AFR) and Amerindian (AMR) ancestry references from the Human Genome Diversity Project using the FLARE software to estimate local and global ancestry in GenPE samples. Statistical significance threshold, for three-way local ancestry analyses, was empirically estimated using STEAM (P = 3.45×10-6).In multivariable logistic regression modelsfor reported ethnicity,AFR-C were 33% more likely to have PE (OR = 1.33; P = 0.02) than HISP women.In models evaluating empirically estimated global GA,AFR was positively associated (OR per 10% increase in ancestry = 1.05; P = 0.002), while AMR (OR = 0.91; P = 0.035) and EUR (OR = 0.95; P = 0.009) were inversely associated with PE. Additionally,adjusting for reported ethnicity in models evaluating global GA and PEchanged estimates only marginally for AFR (OR = 1.04; P = 0.025) and EUR (OR = 0.92; P = 0.009).Evaluation of GA and PE in a subset of women who reported AFR-C ethnicity, showed stronger estimates for all global ancestries: AFR (OR = 1.11; P = 0.013, EUR (OR = 0.82; P = 0.026), and AMR (OR = 0.83; P = 0.01).Association analyses with AFR local GA identified three loci associated with PE.The top locusat chromosome 11, rs2021740 (a smooth muscle enhancer inOTOG1and nearMYOD1), each additional allele of AFR origin associated with 27% increased odds of PE (OR = 1.27; P = 1.13×10-7).The A-allele for this variantis found in greater frequency in AFR reference populations (22%) than in EUR (5%).Subgroup analyses with HELLP syndrome(279 cases and 2364 controls) shows intriguingly opposite findings with increased risk for global AMR and EUR ancestry and decreased risk for AFR ancestry.Using a genetically diverse hispanic population, we showgenetic ancestry is associated with PE independent of reported ethnicityand further demonstrate thepower of admixture mapping to identify a candidate locus for PE.
Abstract 4142117: First Reported Case of Massive Gastrointestinal Bleeding Linked to Piperacillin-Tazobactam in a Patient on Rivaroxaban: A Comprehensive Case Review
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.
Abstract 4146286: Embolization of an Amplatzer Amulet Through a MitraClip Causing Torsades and LVOT Obstruction: A Case Report
Circulation, Volume 150, Issue Suppl_1, Page A4146286-A4146286, November 12, 2024. Introduction:The morphology and blood stasis of the left atrial appendage (LAA) in tandem with disorganized conduction in atrial fibrillation (AF) creates favorable conditions for thrombus formation. Left atrial appendage occlusion (LAAO) devices have become increasingly utilized for stroke prevention in select patients with AF who have contraindications to oral anticoagulation (OAC). We present a unique case of an embolized Amplatzer Amulet LAAO device through a MitraClip into the LV causing polymorphic VT and obstructive shock.Case Presentation:An 80-year-old man with AF and mitral valve prolapse status post MitraClip presented to the hospital for difficulty breathing and palpitations two days after implantation of a 31mm Amplatzer Amulet LAAO device. Notably, he underwent failed attempt at Watchman LAAO implantation due to peridevice leak one year prior. On arrival, he was hypotensive with numerous episodes of polymorphic VT, requiring cardioversion, vasopressors, and mechanical ventilation. TTE located the Amulet within the LV outflow tract (LVOT) creating LVOT obstruction and revealed single-leaflet attachment of the MitraClip. He was evaluated for device retrieval and mechanical support but was deemed not a surgical candidate due to severe thrombocytopenia and guarded prognosis. Despite ongoing resuscitative efforts, the patient became increasingly unstable and died in the cardiac ICU.Discussion:In patients who are unable to tolerate OAC, occlusion of the LAA for stroke prevention has garnered growing interest; however, these devices are not without complication and do not guarantee full occlusion of the LAA. Despite our patient’s history of failing Watchman deployment, he was discharged on the same day after implant of the Amulet device without post-procedure TTE. We postulate that the Amulet device dislodged shortly after deployment and was held within the left atrium by the MitraClip until detachment, allowing for device embolization and severe MR. To our knowledge this is the first documented instance of Amulet device migration into the LV in a patient with a MitraClip. This case highlights the need for heightened post-procedure monitoring, surveillance, and imaging in select patients.
Abstract 4144539: A Heart-pounding Case of Cardiomyopathy in Pregnancy
Circulation, Volume 150, Issue Suppl_1, Page A4144539-A4144539, November 12, 2024. Introduction:Pregnancy-induced cardiomyopathy is typically idiopathic, with no predisposing condition identified. In some cases, women with pre-existing genetic mutations may initially present with cardiomyopathy in pregnancy.Case:A 30-year-old G2P1001 woman presented to Labor&Delivery with frequent palpitations, dyspnea on exertion, and reduced exercise tolerance in the third trimester. Her previous pregnancy was complicated by frequent premature ventricular contractions (PVCs) but otherwise unremarkable. She had a family history of early-onset atrial fibrillation in her mother and a maternal cousin with pregnancy-induced arrhythmias. ECGs and telemetry demonstrated significant ectopy (bigeminy, non-sustained ventricular tachycardia) and atrial arrhythmias including supraventricular tachycardia, atrial tachycardia, and atrial fibrillation (Figure 1). Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 20-25%, reduced from 50% 2 weeks prior. Ectopy was associated with reduced fetal heart rate variability suggestive of fetal malperfusion, for which an urgent C-section was performed at 38 weeks and 6 days. Following delivery, she was started on amiodarone, metoprolol, and spironolactone, as part of guideline-directed medical therapy. Subsequent TTEs showed improvement in EF to 30-35% at 2 days and 45-50% at 4 weeks postpartum. Cardiac MRI showed no evidence of fibrosis or inflammation. Given her maternal family history of arrhythmic events, genetic testing was pursued. Genetic testing revealed a pathogenic SCN5A variant (c.638G >A (p.Gly213Asp)).Discussion:SCN5A variants are associated with dilated cardiomyopathy, conduction disorder, and arrhythmias. It is a rare variant of pregnancy-induced cardiomyopathy. This case highlights the value of genetic testing in patients with significant arrhythmia burden and cardiomyopathy in pregnancy and a family history of cardiomyopathy and arrhythmias. For pregnant women with genetic variants predisposing to arrhythmias and cardiomyopathy, comprehensive longitudinal, multidisciplinary care is essential at a referral center with Cardio-Obstetrics expertise and an Inherited Heart Disease Clinic.
Abstract 4144725: Frequency of Occurrence of, and Risk Factors for, Thromboembolism Before and After Cardiac Surgery in Children with Surgical Congenital Heart Disease: A Case-Control Study
Circulation, Volume 150, Issue Suppl_1, Page A4144725-A4144725, November 12, 2024. Background:Thromboembolism (TE) is a common complication in pediatric congenital heart disease (CHD) requiring cardiac surgery. Data describing the frequency, timing, and factors associated with TE and TE recurrence are limited.Aim:To describe frequency, occurrence, and risk factors for, TE before and after cardiac surgery in children with surgical CHD. The secondary aim was to determine frequency of TE recurrence.Methods:A single-center retrospective study (10/2020-11/2023). Patients
Abstract 4135893: The Importance of Genetic Testing in Diagnosis and Management of Peripartum Cardiomyopathy: A Case Study
Circulation, Volume 150, Issue Suppl_1, Page A4135893-A4135893, November 12, 2024. Introduction:At least 15% of women diagnosed with peripartum cardiomyopathy (PPCM) are found to have a pathogenic genetic variant associated with dilated cardiomyopathy. We present a patient with PPCM who required orthotopic heart transplantation (OHT) for cardiogenic shock. Her explant pathology and genetic testing played a critical role in identifying the etiology of her cardiomyopathy.Case Description:A 22-year-old primigravid woman with a history of asthma presented in labor and underwent a Cesarean delivery for non-reassuring fetal heart tones. She had noted exertional dyspnea, a dry cough, and orthopnea in her final weeks of pregnancy but had an otherwise uncomplicated pregnancy. Immediately following delivery, she suffered a cardiac arrest with pulseless electrical activity and developed cardiogenic shock. She was found to have severe biventricular systolic dysfunction with a left ventricular (LV) ejection fraction of 10%. She was cannulated on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and transferred to our center. She was transitioned from VA-ECMO to an axillary Impella 5.5 device but continued to require inotropic support without evidence of LV recovery. Therefore, she was listed for and successfully underwent OHT. Explant pathology (Figure 1) revealed arrhythmogenic cardiomyopathy (ACM). Her family history was significant for a maternal grandfather who died of an unspecified arrhythmia at age 57. Genetic testing via a commercial arrhythmia and cardiomyopathy panel revealed a pathogenic desmoplakin (DSP)truncating variant (DSPtv) p.Ser1894Leufs*34 in the N-terminal constitutive NMD-competent region, confirming the diagnosis of ACM. The patient had minor cutaneous findings, including curly hair, consistent with the clinical presentation ofDSP-mediated ACM.Discussion:This case highlights the importance of genetic testing in all patients with PPCM, as well as attention to the explant pathology in those who undergo OHT. These practices can elucidate the mechanism of cardiomyopathy, inform the risks of disease progression and of relapse with subsequent pregnancy, and allow for cascade testing of family members.
Abstract 4138792: A Case of Right Coronary Artery Chronic Total Occlusion in a Transplanted Heart: To Stent or Not to Stent?
Circulation, Volume 150, Issue Suppl_1, Page A4138792-A4138792, November 12, 2024. Background:Cardiac Allograft Vasculopathy (CAV) is commonly seen in transplanted hearts. Due to the absence of innervation, many transplanted patients have no symptoms despite extensive disease. This poses a challenge in deciding when to perform coronary interventions. We present a case of significant CAV on surveillance angiogram that posed a challenge in management.Case:A 67-year-old female presented for her fifth surveillance coronary angiography nine and a half years after her heart transplant. The angiogram revealed ostial right coronary artery (RCA) chronic total occlusion (CTO) with left-to-right collaterals as well as diffuse irregularities in the left anterior descending (LAD) and left circumflex arteries. The patient was asymptomatic and two years prior to that, her angiogram revealed no significant disease. Biopsies for the past nine years showed no evidence of allograft rejection. She was subsequently referred for coronary intervention.Due to concern of CTO being a sign of rapidly progressing CAV, it was decided to undergo revascularization of the RCA. Antegrade approach was performed with guidance from contralateral injections. Three overlapping drug-eluting stents were deployed proximally-distally using intravascular ultrasound guidance. Surveillance angiography nine months later showed patent RCA stents with no significant disease otherwise. Eighteen months later, angiography demonstrated CTO of the mid LAD and patent RCA stents with mild in-stent restenosis in the most distal RCA stent. The patient remained asymptomatic.Discussion:CAV develops in fifty percent of transplanted hearts within 10 years and requires close surveillance. In this case, revascularization of the RCA CTO resulted in maintaining graft function for at least two additional years as the development of LAD CTO may have resulted in graft failure had the RCA CTO not been intervened upon. CTO revascularization in CAV has the potential to prolong graft viability and delay the need for re-transplantation. Further studies related to CTO revascularization, especially in asymptomatic transplanted patients, are needed to understand the impact on morbidity and mortality in this patient population.
Abstract 4136274: A Case of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) Complicated by a Ventricular Septal Defect (VSD)
Circulation, Volume 150, Issue Suppl_1, Page A4136274-A4136274, November 12, 2024. Case:A 69-year-old woman with a history of hypertension and tobacco use disorder presented with acute chest pain. The patient was found to have classic anterior ST elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) with high-sensitivity troponin of 12,772 ng/L and was taken emergently to the catheterization laboratory. Coronary angiography showed tortuous coronary vessels though without evidence of obstructive coronary artery disease, plaque rupture, ulceration, dissection, or vasospasm. Transthoracic echocardiogram showed an apical ventricular septal defect (VSD) with normal left ventricular systolic function of 60%. Cardiac computed tomography (CT), confirmed a discrete apical VSD that was 7.93 mm in diameter and multiple small VSDs distally in the septum. Right heart catheterization revealed severe left-to-right shunting with a ratio of pulmonary blood flow to systemic blood flow (Qp:Qs) of 2.8.Early surgical repair of the apical VSD was pursued despite known high operative risk given the hemodynamic significance of the shunt. The patient developed ongoing hemodynamic instability from cardiogenic shock with inability to ween from intra-aortic balloon pump (IABP). Unfortunately, because of the location of the residual VSDs and elevated panel-reactive antibody testing of 98%, the patient was deemed to not be a candidate for percutaneous closure or heart transplantation, respectively.Discussion:An acquired ventricular septal defect (VSD) is a rare and catastrophic complication of myocardial infarction, typically with a culprit obstructive coronary artery lesion identified on coronary angiography. Acquired VSDs in myocardial infarction with nonobstructive coronary arteries (MINOCA) is an even more rare phenomenon. Possible causes include low flow, inflammation, intimal disruption, or vasospasm of coronary arteries. Our case highlights that MINOCA can present with life-threatening complications similar to obstructive STEMI.The timing of intervention and treatment approach of acquired VSDs remains an area of debate. The life-threatening effects of VSDs make it critical to manage in a multidisciplinary manner involving advanced imagers, interventional cardiologists, cardiothoracic surgeons, and heart failure specialists. This case emphasizes the importance of maintaining a high index of suspicion for abnormal coronary anatomy, even in patients with MINOCA, and prompt interdisciplinary decision making to reduce mortality.
Abstract 4138350: Candidemia in Patients with Left Ventricular Assist Device-A Case Series
Circulation, Volume 150, Issue Suppl_1, Page A4138350-A4138350, November 12, 2024. Introduction:Candidemia is rare but associated, have significant morbidity and mortality. Outcomes are not well-characterized in patients with left ventricular assist devices (LVADs). With an increasing number of patients living with LVADs, we sought to characterize risk factors to help optimize outcomes for this high-risk population.Methods:We retrospectively reviewed records of 97 patients who underwent LVAD implant between January 2012 to May 2024 at Indiana University Health, Indianapolis Indiana. Demographic and clinical data were extracted. Candidemia was defined as a positive blood culture with candida species.Result:We identified three patients with candidemia, with an overall attack rate of 3.09%. All patients had a HeartMate III (HM3) at the time of infection. The mean age of patients was 40.3 years (Range 29.0 – 58.0 years) and mean BMI was 35.7 kg/m2(Range, 30.0 – 42.0 kg/m2). One patient grewCandida aurisandCandida tropicana,the other patient grewCandida aurisand the third patient grewCandida globrata.All patients had an automatic implantable cardiac defibrillation, a peripherally inserted central catheter line, and right heart failure. Two patients had driveline infections (one fungal, one bacterial) while one patient developed LVAD endocarditis with a right ventricular outflow tract vegetation. Two patients had persistently positive blood cultures despite treatment with a multi-drug anti-fungal regimen (Flucytosine, Amphotericin B and micafungin) and expired. The third patient initially cleared her blood cultures after treatment with IV micafungin only but was re-admitted with muti-organ failure and expired. Summarily, all patients with candidemia died with a mortality rate of 100%. None of the patients were candidates for heart transplantation. Average survival from the time of diagnosis of candidemia was 5 months (Range 1.0 – 11.0 months). RHF, chronic DL infection and high BMI were associated with candidemia in our series.Conclusion:Candidemia in LVAD patients, while less common than bacterial infections, carry high mortality without cardiac transplantation (100% mortality in our cohort). Its rare occurrence makes it challenging to identify reversible risk factors, leading to poor survival. Multicenter registries are needed to fully elucidate these risk factors and determine effective treatment strategies.
Abstract 4139677: A rare case of ventriculobronchial fistula caused by an epicardial defibrillator patch
Circulation, Volume 150, Issue Suppl_1, Page A4139677-A4139677, November 12, 2024. Background:Epicardial patch defibrillators (EPDs) were commonly implanted in the 1990s for secondary prevention of sudden cardiac death. Despite being largely obsolete, some EPDs remain in patients and can cause late complications. This case highlights such a scenario.Case:A 75-year-old female with a history of cardiac arrest 30 years ago presented with shortness of breath and left leg swelling. She had idiopathic ventricular fibrillation in 1992, treated with an EPD (Picture 1A), later replaced by a transvenous ICD.She was diagnosed with left femoral deep venous thrombosis and bilateral pulmonary embolism and started on therapeutic anticoagulation. She experienced massive hemoptysis, leading to respiratory and cardiac arrest, but was resuscitated. A CT angiogram showed no active bleeding but noted the EPD was close to the lower lobe of the left lung. Upper gastrointestinal endoscopy showed no active bleeding. Bronchoscopy revealed clots in the left lower lobe. Despite empiric bronchial artery embolization, hemoptysis persisted. A repeat bronchoscopy showed reaccumulation of clots. A repeat CT angiogram indicated contrast extension into the ventricular myocardium near the EPD but no lung spillage suggestive of pseudoaneurysm (Picture 1B).She was transferred to our institution for further evaluation. A coronary angiogram revealed normal arteries, while a left ventriculogram revealed contrast extravasation through the lateral wall (Picture 1C). An urgent surgery revealed two EPDs: anterior and lateral. The lateral EPD had eroded into the ventricle, creating a ventriculo bronchial fistula (Picture 1D). The lateral EPD was removed (Picture 1E); the anterior EPD was left in place (Picture 1F). The ventricular defect was debrided and repaired. Postoperative recovery was successful, with no further hemoptysis, and the patient was discharged to a rehabilitation facility.Discussion:EPDs are no longer used due to high failure rates and complications like scar formation and constrictive pericarditis. However, patients with EPDs from the 1990s may present with delayed complications. Accurate diagnosis using multimodality imaging and early management is crucial to reduce morbidity and mortality.
Abstract 4140763: A Case of Clozapine-Induced Myocarditis: An Under-described Side Effect
Circulation, Volume 150, Issue Suppl_1, Page A4140763-A4140763, November 12, 2024. Case Descripton:A 34-year-old male with Schizophrenia was transferred from inpatient Psychiatry unit for chest tightness, fevers andtachycardia after testing positive for COVID-19. Further history revealed antipsychotics had been recently adjusted with the addition of Clozapine 1 month prior to presentation.On presentation, he was febrile (39.1°C) and tachycardic to the 146 in sinus tachycardiac on EKG and Telemetry. He was euvolemic on exam with tachycardia but no murmurs or discernable friction rub.Labs revealed no leukocytosis but an elevated C-reactive protein (CRP) 168mg/L, high-sensitivity troponin (474ng/L) and brain-natriuretic peptide (BNP, 176 pg/mL, no baseline value). Otherwise, TSH, ANA and RF were normal. Repeat Respiratory Viral Panel, respiratory biofire and blood cultures were unrevealing. Imaging (CXR and Chest CTA) were normal. TTE showed normal function and small pericardial effusion. Cardiac MRI was limited by inability to tolerate the scan but reported preserved biventricular function. The home facility was contacted and reported initial COVID testing was expired and invalid. Psychiatry was consulted for suspected clozapine-induced myocarditis and recommending holding Clozapine while resuming Risperdione.The patient reported subjective improvement in symptoms and return to baseline. Feversdefervesced and tachycardiac resolved.Discussion:Rare (0.06%-3.88% reported incidence) and not well-described, Clozapine-induced myocarditis can be a challenging entity to identify. In the literature, it is defined as having elevated CRP or detectable troponin and at least 1 sign or symptom of myocarditis, in the absence of alternative plausible etiologies. Symtoms typically onset between 1-4 weeks of medication initiation. Mortality can range between 10-30%. The acute history of symptoms, elevation in CRP and troponin shortly after medication initiation suggested a diagnosis of clozapine-induced myocarditis. The absence of reduction in systolic function and indeterminant MRI are nocompelling against clozapine-induced myocarditis in lieu of other more plausible diagnoses. Early cessation and symtpomatic managemnt is standard therapy.Conclusion:Clozapine-induced Myocarditis is an entity not well-described but carries a significant mortality risk. Perhaps cardiac-monitoring guidelines must be implemented in addition to the currently adopted montiroing for agranylocytosis with clozapine.
Abstract 4140682: Clinical Case: Flipping the Script: Tackling CAD in Dextrocardia During Cardiac Catheterization
Circulation, Volume 150, Issue Suppl_1, Page A4140682-A4140682, November 12, 2024. Introduction:Dextrocardia is a rare congenital condition where the heart’s apex points to the right, with an incidence of about 0.01%. Patients usually have a normal life expectancy unless other structural heart diseases are present. The prevalence of atherosclerotic coronary artery disease (CAD) in these individuals is believed to be similar to that of the general population.Due to its rarity, data on coronary interventions in this subset are scarce, with available literature mostly limited to case reports. Patients with dextrocardia present a diagnostic challenge, particularly in the context of acute coronary syndrome.Case Presentation:A 49-year-old male with a medical history of dextrocardia, hypothyroidism, dyslipidemia and hypertension was referred to a cardiologist by his primary physician due to a 3-week history of unstable angina. His vital signs were normal, and the physical examination was unremarkable. Electrocardiogram (ECG) showed a prominent S wave in the left-sided leads and a prominent R wave in the right-sided chest leads, suggesting dextrocardia. Although he had a normal echocardiogram and stress test a year ago at a different hospital, due to his symptoms and intermediate-high risk probability of coronary artery disease (CAD), the decision was made to proceed with a cardiac catheterization using a trans-radial approach with a horizontal sweep technique. During the procedure, a 6-French tiger catheter (TIG) was guided into the left coronary sinus and advanced into the left ventricle under fluoroscopic guidance.The left main coronary artery was widely patent bifurcating into the left anterior descending and left circumflex. The left circumflex had 80% proximal stenosis with minimal luminal irregularities in the mid to distal portion. After guidewire crossing, balloon angioplasty was performed, and a drug-eluting stent was deployed. An intravascular ultrasound was also performed, which was negative for vessel dissection. There were no post-procedure complications, and the patient was discharged on beta blockers and dual antiplatelet agents.Conclusion:Performing cardiac catheterization in patients with dextrocardia presents unique technical challenges due to the mirror-image anatomy. This case report highlights the modifications in standard techniques, emphasizing the need for specialized skills and strategies to achieve successful outcomes in such cases.