Risultati per: La gestione del paziente depresso da parte del medico di medicina generale: case reports

Circulation, Volume 150, Issue Suppl_1, Page A4145609-A4145609, November 12, 2024. Introduction:Cannabis has been increasingly used as a recreational drug. Its cardiovascular effects depend on several factors, including the exact composition, route of administration, dose, and duration of use. Here we report a case of cannabis induced junctional bradycardia in a patient with cardiovascular comorbidities.Case description:A 68-year-old male with history of chronic systolic heart failure, coronary artery disease, diabetes, hypertension and chronic kidney disease was referred to the hospital from outpatient clinic for bradycardia with heart rate 25-35. Patient did not report any symptoms and was hemodynamically stable. He was euvolemic on physical exam. Electrocardiogram (ECG) and telemetry revealed junctional bradycardia with heart rate in 30s and sinus pauses (5-7 seconds). Initial laboratory analysis was unremarkable. He was admitted for further workup of bradycardia. His home medications included metoprolol succinate 25mg daily which was held given bradycardia. Urine drug screen was positive for cannabis. Patient endorsed that he had recently started smoking marijuana to help him with sleep and anxiety. Echocardiogram was unchanged from baseline. He was monitored on telemetry and the heart rate improved to 60-70s in about 24-48 hours without any other intervention. The temporal relationship between cannabis initiation and spontaneous resolution of bradycardia favored a potential causal link for cannabis- induced mechanism for the junctional bradycardia. Patient was resumed on metoprolol prior to discharge and tolerated it well without any bradycardic episodes establishing further that this was not iatrogenic bradycardia. He was counseled to abstain from cannabis use.Conclusion:At low to moderate doses, cannabis can lead to a surge in sympathetic activity causing tachycardia and hypertension, while parasympathetic activity is predominant at higher doses, causing bradycardia and hypotension. Understanding these nuanced effects is crucial for clinicians when evaluating patients especially those with pre-existing cardiovascular conditions. Guidelines should be refined for safer use as the landscape of cannabis legislation evolves.

Circulation, Volume 150, Issue Suppl_1, Page A4125893-A4125893, November 12, 2024. Introduction:Drug combinations offer increased therapeutic efficacy and reduced toxicity and plays a vital role in treating chronic complex diseases. Understanding a drug combination’s mechanism of action (MoA) can provide important insights into its therapeutic efficacy. The MoA of many FDA-approved drugs, however, often remains unclear.Methods:In this study, we investigated the combination of a statin [atorvastatin (ATO) or simvastatin (SIM) plus ezetimibe (EZE)] and utilized drug-treated RNA-seq transcriptome data from SOAT2-only-HepG2 cells (treated with ATO 5 umol/L, EZE, 25 umol/L, their combination or vehicle) and from liver biopsies of patients with uncomplicated cholesterol gallstone disease in the Stockholm Study (a single-blind, randomized trial with SIM 80 mg daily, EZE 10 mg daily, their combination, or placebo) to decipher the underlying molecular mechanisms of the drug combination. We proposed a Boolean logical modeling framework to simulate the MoA of a drug combination. Specifically, fourteen two-variable Boolean models were used to describe the combinatory relationships of ATO/SIM and EZE. Thereafter, a pattern matching approach was applied to associate drug-induced differentially expressed genes with the idealized differential expression templates derived from Boolean models.Results:We found 1,560 and 594 genes differentially expressed in at least one treatment condition in SOAT2-only-HepG2 cells and liver biopsies, respectively. Our analysis revealed both expected and novel combinatorial modes of ATO/SIM and EZE. For example, ATO independently activates downstream genes (i.e. B4(ATO,EZE)=ATO), and ATO and EZE synergistically inhibits downstream genes (i.e. B15(ATO,EZE)=NOT (ATO AND EZE)) , as the two most prevalent MoAs in SOAT2-only-HepG2 cells (Figure 1). Similarly, the combination of SIM and EZE synergistically inhibiting downstream genes was also the most prevalent MoA in the liver biopsies. We mapped the downstream genes of each combinatorial mode to the human interactome and obtained underlying subnetworks, which are important for understanding the therapeutic effects of the drug combination. Functional enrichment and disease-association analyses of the downstream suggest the additional therapeutic indications of the drugs.Conclusion:Drug-induced transcriptomes are informative in deciphering the MoA of drug combinations using Boolean logical modeling. This framework can be easily extended to the combinations of three drugs.

Circulation, Volume 150, Issue Suppl_1, Page A4129440-A4129440, November 12, 2024. Background:Ventricular stunning refers to a transient mechanical dysfunction of the myocardium, typically manifesting in response to ischemic insults, reperfusion injury, inflammatory states, or neurohormonal overload. Here, we present an unusual case of ventricular stunning precipitated by direct current electrical cardioversion (DEC).Case Report:A 73-year-old man with a history of heart failure with reduced ejection fraction, paroxysmal atrial fibrillation (AF), coronary artery disease, and chronic kidney disease was admitted to a Veterans Affairs hospital for heart failure exacerbation. His hospitalization was complicated by recurrent episodes of symptomatic AF with ventricular rates in the 120-150’s. This was initially managed with intravenous amiodarone and eventually DEC. He continued to experience symptomatic episodes of AF. Later in the hospitalization a repeat DEC with a single 200 joule shock was performed with restoration of sinus rhythm. Several hours afterwards he was found to be unresponsive and hypotensive. Cool extremities and rising serum lactate raised suspicion for cardiogenic shock resulting in transfer to the intensive care unit where vasopressor and inotropic support were initiated. Echocardiogram revealed a precipitous decrease in left ventricular ejection fraction from 25% to 5%. Serum troponin concentrations were unchanged from prior and ECGs demonstrated rate-controlled AF.Clinical Decision Making:This case highlights an episode of unexpected decrease in cardiac output following an otherwise routine repeat DEC for recurrent AF requiring escalation to mechanical circulatory support. His decompensation worsened, necessitating transfer to the local university center for placement of catheter-based miniaturized ventricular assist device (Impella 5’5). Over the subsequent days, with supportive care, his left ventricular ejection fraction recovered to baseline, and mechanical and inotropic support were withdrawn.Conclusion:Ventricular stunning, leading to cardiogenic shock, is a rare and incompletely understood complication of DEC. It warrants consideration when monitoring patients after cardioversion. Implementing vigilant observation protocols post-DEC to detect ventricular stunning and predisposing risk factors could significantly enhance clinical management strategies.

Circulation, Volume 150, Issue Suppl_1, Page A4124677-A4124677, November 12, 2024. Introduction:Chagas disease is a significant cause of tropical disease-related mortality. It presents in acute, indeterminate, and chronic phases, with chronic cardiomyopathy being the most severe form, leading to heart failure, arrhythmias, and sudden cardiac death. Conventional echocardiography often fails to detect early subclinical dysfunction, whereas Global longitudinal strain (GLS) may provide earlier detection of myocardial strain abnormalities. Left ventricular dysfunction is an independent predictor of mortality and GLS is an emerging modality that may aid early detection of cardiac involvement.Objective:This study aims to compare left ventricular function using multiple echocardiographic parameters between patients with indeterminate and chronic forms of Chagas disease and to perform a systematic literature review.Methods:The observational study involved 11 patients (mean age 76.36 years) from a tertiary hospital in Brazil, classified as indeterminate (45%) or chronic (55%). Serological confirmation and detailed echocardiographic evaluations, including GLS, were performed. A systematic literature review was also conducted on GLS in Chagas cardiomyopathy.Results:Patients with chronic Chagas disease showed significantly lower LVEF and GLS compared to those with the indeterminate form. Segmental strain analysis revealed consistent contractility reductions across specific ventricular segments in both groups.Discussion:Chagas cardiomyopathy often leads to dilated cardiomyopathy with significant arrhythmias and heart failure. GLS can detect early myocardial changes even before a significant drop in LVEF, indicating its potential for early diagnosis and better management of Chagas cardiomyopathy. Literature review supports the use of GLS for detecting early cardiac involvement and predicting adverse outcomes.Conclusion:Incorporating GLS with conventional echocardiography offers enhanced early detection of myocardial changes in Chagas disease. While promising, further research is needed to establish the clinical significance and impact of these techniques in routine practice.

Circulation, Volume 150, Issue Suppl_1, Page A4145503-A4145503, November 12, 2024. Background:Highly sensitized recipients are expected to have higher wait-time for heart transplant, however, their sensitization status does not grant them higher priority.Methods:UNOS database was analyzed for adult heart transplant recipients from Oct 2018 to April 2024 with reported calculated panel reactive antibodies (cPRA). Retransplant and multiorgan transplant recipients were excluded.Results:Total 10801 recipients were identified. High cPRA (≥70% cPRA) group constituted only 5% of the listed patients. However, 13% of listed female recipients fell in this category (compared to

Circulation, Volume 150, Issue Suppl_1, Page A4135360-A4135360, November 12, 2024. Case presentation:A 64-year-old man presented with one day of chest pain. Initial evaluation showed elevated cardiac enzymes (CE) and normal eosinophil count. Electrocardiogram (EKG) was unremarkable. Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 40% and a moderate-large pericardial effusion with signs of tamponade. Pericardiocentesis was deferred due to the lack of a safe window. Left and right heart catheterization showed no occlusive disease or chamber pressure equalization. The patient developed worsening shock, raising suspicion for myocarditis and prompting an endomyocardial biopsy (EMB). He was placed on extracorporeal membrane oxygenation (ECMO) on day 3. The EMB resulted as eosinophilic myocarditis (EM), and high dose Methylprednisolone was started. He was decannulated from ECMO on day 10. Intra-operative transesophageal echocardiogram (TEE) post-decannulation showed a normal EF without segmental abnormalities. Three hours later, a rise in CEs was noted, and EKG showed ST elevations inferiorly. TTE showed a reduced EF with multiple segmental abnormalities concerning for myocardial infarction. A repeat coronary angiogram was unremarkable. Due to the residual pericardial effusion, the patient underwent a pericardial window draining 200 cc of serosanguinous fluid. Intra-operative TEE showed an EF of 20% with no improvement after drainage. He had a cardiac arrest during the procedure and was placed back on ECMO. High-dose steroids were resumed along with intravenous immunoglobulin. Despite interventions, the patient continued to deteriorate and he ultimately expired.Discussion:EM has high mortality and a variable course, often requiring EMB for diagnosis. As in our case, about 25% of cases present without peripheral eosinophilia. Pericardial effusion occurs in 34% of cases and tamponade in 6%. A distinct feature of this case is the decompensation associated with ST elevation and segmental abnormalities, thought initially to be myocardial infarction (MI), after an initial response to steroids. While the etiology of such decompensation is unclear, relapsing EM in the setting of tapering steroids is one explanation, as myocarditis and MI can share similar clinical features. Another explanation is cardiac tamponade, which has also been reported to mimic MI and myocarditis. Air embolism from ECMO decannulation is another possibility, though air embolisms may include cerebrovascular pathology, which was not observed.

Circulation, Volume 150, Issue Suppl_1, Page A4138546-A4138546, November 12, 2024. Introduction:Takotsubo cardiomyopathy (TCM) is a reversible cardiac condition often precipitated by emotional or physical stress. Certain medications have also been implicated. While prognosis is generally favorable, associated QTc prolongation and ventricular arrhythmias can be life threatening, necessitating identification of potential triggers. This report highlights TCM in a patient using high-dose berberine, a plant alkaloid known for its hypoglycemic properties.Case description:A 69-year-old female with a history of type 2 diabetes mellitus, and hyperlipidemia presented after a syncopal event. It was preceded by sudden onset of dizziness, nausea, and vomiting. She had been using berberine for a year to lower her blood sugar and had recently switched to a higher dose of a more potent formulation. Vitals were unremarkable. Initial evaluation revealed a prolonged QTc interval of 659 ms (Figure 1A) and elevated troponin-I levels. She was treated with intravenous magnesium, which improved her QTc to 540 ms and revealed new T-wave inversions in the precordial leads. Echocardiogram showed an ejection fraction (EF) of 35%, with LV apical akinesia and hypercontractile basal segments. Cardiac catheterization ruled out significant coronary artery disease, leading to a diagnosis of TCM. Berberine was discontinued, and guideline-directed medical therapy was initiated. Given the presentation with syncope and high suspicion of aborted sudden cardiac death (SCD), she was discharged with a wearable cardioverter-defibrillator (WCD) as a precaution due to the risk of ventricular arrhythmias during recovery. At her 8-week follow-up, QTc and EF had normalized (Figure 1B), prompting WCD removal.Conclusion:The pathophysiology of berberine-induced cardiomyopathy remains uncertain and requires further research. This case underscores the importance of recognizing the potential cardiotoxic effects of berberine, particularly when used in high doses. A thorough medication and supplement history is crucial in patients presenting with unexplained cardiac symptoms. The reversible nature of TCM, when promptly recognized and treated, highlights the need for comprehensive follow-up to ensure recovery of cardiac function.

Circulation, Volume 150, Issue Suppl_1, Page A4140574-A4140574, November 12, 2024. Introduction:Atrial myxomas are cardiac tumors that can cause arterio-occlusive diseases due to embolization of myxomatous fragments. Treatment is through prompt surgical resection, with recurrence rates relatively rare. Herein, we present a case of recurrent left atrial myxoma with hemorrhagic, cerebral embolization.Case Report:A 34-year-old male presented with acute onset numbness and tingling of the left arm. He was vitally stable with unremarkable physical examination or bloodwork. CT Head showed multifocal brain metastases in the bilateral parietal and left frontal lobes. Brain MRI demonstrated multiple hemorrhagic masses throughout the cerebral hemispheres with vasogenic edema. The patient’s past medical history was pertinent for bilateral occlusion of the femoral and popliteal arteries, with workup revealing a left atrial myxoma that was surgically resected in 2005. The patient presented again in 2021 with right facial paresthesia and arm weakness. Brain MRI showed bilateral cortical and subcortical MCA ischemic strokes. TEE confirmed the recurrence of a left atrial myxoma, requiring a repeat sternotomy and resection.Since then, the patient was frequently hospitalized with seizures and strokes. Surveillance brain MRIs consistently demonstrated hemorrhagic masses of varying sizes and vasogenic edema, localized to the watershed territories of the cerebral arteries. The patient underwent left frontal craniotomy and resection of a left frontal lobe lesion in 2023, with pathology specimens representing organizing cerebral hemorrhage of unclear etiology. Repeat echocardiograms did not show recurrence of a myxoma. The overwhelming clinical opinion states that these are myxomatous metastasis from before the patient’s last cardiac surgery. Given the tumor burden and progressive nature of the disease, the patient was deemed inappropriate for neurosurgery or chemotherapy.Discussion:Recurrence after surgical resection of atrial myxomas is rare, with 0.5 cases reported per 1000-person years, and is mainly attributed to inadequate surgical resection. Limited research exists regarding malignant atrial myxomas. The prevailing hypothesis points to the neoplastic transformation of myxomatous emboli into malignant lesions. Our patient is a unique case of a recurrent atrial myxoma with symptomatic cerebral metastasis. This case highlights the importance of adequate resection of cardiac myxomas to prevent the malignant transformation of an otherwise benign tumor.

Circulation, Volume 150, Issue Suppl_1, Page A4119267-A4119267, November 12, 2024. Background:Sarcoidosis, a systemic granulomatous inflammatory disorder can involve various organs, including the heart but isolated bi-atrial cardiac involvement is rare. Advanced cardiac imaging especially in atypical presentations, can aid in early diagnosis.Case:A 59 year-old man with history of biopsy-proven pulmonary sarcoidosis presented with non exertional chest pain for 2 months. EKG, cardiac enzymes, and Initial echocardiogram(TTE) was unremarkable. Stress echocardiogram ruled out myocardial ischemia. CT scan noted mediastinal lymphadenopathy consistent with known sarcidosis. In absence of other explainable etiolgies for chest pain, Cardiac MRI was done and showed preserved biventricular function, subepicardial enhancement in the basal inferior, inferolateral, and anterolateral walls. The enhancement raised suspicion for CS. However, symptoms resolved spontaneously, cardiac workup paused and he was monitored conservatively with serial Echocardiogram(TTE) until onset of dyspnea 3 years later. Repeat TTE and EKG then noted newly enlarged left atrium and atrial tachycardia. Further testing with Cardiac positron emission tomographic imaging with F-18 fluorodeoxyglucose (FDG-PET CT) showed abnormal myocardial uptake in both atrial posterior walls but no ventricular involvement, indicative of isolated bi-atrial inflammation in CS. He was treated with prednisone and methotrexate. Successful symptom and inflammation resolution on FDG-PET CT occurred in 3 monthsDiscussion:CS is rare and seen clinically in about 5% and diagnosed postmortem in 25% of sarcoidosis cases. Symptoms vary widely, with potential for severe heart complications. Left ventricle and interventricular septum are commonly involved, but isolated bi-atrial involvement is rare. Early diagnosis aided by Cardiac MRI and FDG-PET CT is crucial. Prednisone is mainstay of treatment, often combined with methotrexate. Cases of concurrent atrial CS involvement and bi-atrial fibrosis with Left ventricular hyperenhancement are documented, but this is the first known report of isolated bi-atrial hyperenhancement on FDG-PET CT for CS. This case highlights the need for symptom correlation with clinical and imaging follow-up, especially in atypical presentations.

Circulation, Volume 150, Issue Suppl_1, Page A4114597-A4114597, November 12, 2024. Background:Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of ACS, myocardial infarction, and sudden death particularly among young women and individuals with few conventional atherosclerotic risk factors. We reveiwed possible risk factors that could predispose to SCAD.Methods:We reviewed 13 consecutive patients presenting with SCAD across three different institutions over a period of 5 yrs and determined risk fatcors associated with this disase entity.Results:13 patients presented with SCAD represented % 0.5 of the total number of patients who underwent cardiac cathaterizations for chest pain requiring admissions. 11/13 (84%) were female. 5/13 (38%) were Caucasian or Hispanic, and 3/13 (23%) were African-American. Mean age age was 49.3 + years. 8/13 (61%) had associated hyperlipidemia with LDL levels > than 110 mg/dL, 9/13 (64%) had an A1c < 5.6% and only 1/13 (0.07%) had A1c of 6.4%. HTN was present in 6/13 (46%) of patients, and family history of SCD or heart disease were only seen in 2/13 (15%). None of the patients had features suggestive of associated fibromuscular dysplasia or connecive tissue disease. D-dimer was elevated in 5/13 (38%) with average value of 1578 ng/dL. Inflammatory markers were reviewed, only 3 patient has had ESR and CRP ordered, and only 1/3 had a mildly elevated CRP 3.9 mg/dL. Only 1/13 (0.07%) required intervention which was due to further drop in her ejection fraction requiring PCI, with improvement in her symptoms. All patients were treated with dual anti-platelet therapy for 1 year, 1 was discontinued due to persitent chest pain and decision was made to treat with only aspirin. Traditionally, risks for SCAD were thought to be due to non-atheresclerotic factors, however our case series shows that more then 60% of patients had elevated LDL's and 46% with hypertension, implying that traditional atheresclerotic risk factors should not be ignored and may play a crucial role. Autoimmune diseases were not found in any of our patients.Conclusion and implications:In this series patients who had SCAD had conventional risk factors of CAD including HLD and hypertension. The variability of co morbidities makes the identification of specific risk factors very difficult and none of the patients had Fibromuscular dysplasia or any signs of inflammation. Elevated D Dimer was also seen in a majority of patients, and all but one was managed medically with a favorable outcome

Circulation, Volume 150, Issue Suppl_1, Page A4145376-A4145376, November 12, 2024. Background:Carbon monoxide (CO) poisoning is a significant public health threat, with emerging attention on its cardiovascular consequences such as myocardial injury, heart failure, and arrhythmias. Notably, atrial fibrillation (AF) has been sporadically reported, suggesting a potential link between CO exposure and cardiac dysrhythmias.Case Report:A 72-year-old female with hypothyroidism and IBS presented to the emergency department with sudden gait imbalance, dizziness, and an occipital headache. Her ECG showed new-onset atrial fibrillation, with subsequent unremarkable echocardiography and brain imaging. Remarkably, her husband exhibited similar symptoms and both had recently been camping. Suspecting CO poisoning, carboxyhemoglobin was tested and found to be 2.9%, with no methemoglobinemia. The patient spontaneously converted to normal sinus rhythm during hospitalization and maintained it during hospitalization without hyperbaric oxygen therapy.Systematic Review of Case Reports: We identified seven cases of carbon monoxide-induced atrial fibrillation from 45 citations. Patients were mostly male (57.14%), aged 21 to 82, and presented with diverse symptoms, primarily headache (57.1%) and nausea (57.1%). Rapid ventricular response occurred in 85.7% of cases, none with a prior history of atrial fibrillation. Most (85.7%) returned to normal sinus rhythm upon discharge, and 71.4% maintained it on follow-up. Normobaric oxygen therapy was given in 57.1% of cases, and hyperbaric oxygen in 42.9%. Most patients (85.7%) had no known cardiovascular disease.Discussion:Despite being underexplored, evidence suggests a notable escalation in dysrhythmia risk, particularly in patients with pre-existing cardiovascular conditions, following acute CO poisoning. Potential mechanisms for CO-induced dysrhythmias include the strong binding of CO to hemoglobin, resulting in hypoxia-induced myocardial changes, and molecular alterations affecting cardiac voltage-gated channels.Conclusion:While the association between acute CO poisoning and dysrhythmias warrants further investigation, emerging evidence underscores the necessity of raising awareness among healthcare providers regarding the potential cardiovascular consequences of CO exposure.

Circulation, Volume 150, Issue Suppl_1, Page A4141955-A4141955, November 12, 2024. Introduction:Whereas low testosterone levels have been associated with poor cardiovascular outcomes and testosterone replacement therapy (TRT) in middle-to-older age adults with cardiovascular risk factors is considered safe, there is little data on the adverse cardiovascular effects of TRT in young adults.Case Report:A 38-year-old male with a past medical history of hypogonadism, recently started on intramuscular testosterone cypionate injections, presented to the hospital with altered mentation. Laboratory workup was remarkable for hemoglobin of 19 g/dL. Computed tomography (CT) angiogram of the head demonstrated a left middle cerebral artery infarct with a filling defect, requiring mechanical thrombectomy. A transthoracic echocardiogram (TTE) was done which revealed a dilated left ventricle (LV) with severely reduced LV systolic function, EF 20%, and global hypokinesis. There was no LV thrombus or evidence of a patent foramen ovale with contrast saline injection. He did not have any episodes of atrial fibrillation on telemetry monitoring. His hospital course was further complicated by an inferolateral ST elevation myocardial infarction (STEMI) due to distal left anterior descending (LAD) artery occlusion. He underwent drug-eluting stent placement and was started on dual antiplatelet therapy. Repeat TTE demonstrated new apical akinesis along with an LV apical thrombus of 1.1 x 0.8 cm. CT abdomen/pelvis with contrast demonstrated left renal and right iliofemoral thrombosis and the patient was also started on systemic anticoagulation.Discussion:Data suggests that physiologic levels of testosterone exhibit cardioprotective effects and low testosterone levels are associated with increased cardiovascular mortality. However, studies have also shown that testosterone use is associated with an increased risk of thrombosis and coronary artery disease. Additionally, testosterone use has been associated with myocardial apoptosis and adverse cardiac remodeling from dysregulation of androgenic receptors, which results in dilated cardiomyopathy. There is an ongoing debate on the safety of TRT, however, studies on TRT have largely included the middle and older male population and there is little data on younger patients. Herein, we demonstrate a case of TRT in a patient with several cardiovascular risk factors, who developed evidence of possible TRT-associated cardiomyopathy in addition to hypercoagulability.

Circulation, Volume 150, Issue Suppl_1, Page ASu1012-ASu1012, November 12, 2024. Introduction:Traditional sternal piston-type CPR (SP-CPR) is associated with rib and sternal fractures in a large fraction of porcine cardiac arrest studies. Most investigators using SP-CPR “mold” the pig’s precordium to prevent piston movement and enhance the “cardiac pump.” This molding is essentially disruption of the sternocostal joints. Although circumferential constriction CPR (CC-CPR) applies more motive force to the chest, it spreads this force over a much larger area. This results in a less concentrated force which may cause less skeletal injury.Hypothesis:CC-CPR may be associated with a lower incidence of thoracic skeletal injury.Methods:Retrospective observational report of multiple porcine studies. Ventricular fibrillation was induced in female Yorkshire swine (n = 30, 28±5 kg). CPR was provided by means of pneumatic CC-CPR prototypes in all animals. Most received thoracoabdominal CPR with pneumatic bands around both the chest and the abdomen. Thoracic vest pressures ranged from 180–300mmHg with constriction rates from 80–120 per minute and duty cycles from 30-50%. Duration of resuscitation was typically 20 min. Examination for injuries was via visual inspection and palpation both externally and internally during postmortem by the team veterinarian. We used the fracture rates reported in previous porcine CPR studies as a historical control.Results:In this large series of porcine studies with CC-CPR, which included per-constriction forces as great as 400kg and relatively long intervals of resuscitation, only 2 rib fractures were found, a rate of 0.07 fractures per pig. No sternal or chondral injuries were detected. We found four prior studies, all using SP-CPR, that appeared to reliably report a CPR-related fracture rate. The average rate was 4.45±1.6 per animal. Sternocostal joint disruption from “molding” did not appear to be reported as injury in published studies.Conclusion:CC-CPR appears to be associated with a remarkably low rate of thoracic skeletal injury in porcine models, compared with historical controls. It is not known if this enhanced safety in animals will translate to patients in the clinical setting, most of whom will have received manual and/or sternal piston type CPR before CC-CPR can be initiated.

Circulation, Volume 150, Issue Suppl_1, Page A4138487-A4138487, November 12, 2024. Introduction:A 79-year-old male patient with a history of surgical AVR presented with severe bioprosthetic aortic stenosis requiring valve-in-valve TAVR. The plan was to place an Evolut CoreValve after intentionally fracturing the basal ring of his surgical valve. Through an 18F sheath, a 25mm x 4.5cm True balloon was advanced to the surgical valve over a Lunderquist wire. However, the balloon ruptured immediately after fracturing the valve ring.Decision making:Efforts were made to remove the ruptured True balloon while maintaining the position of the wire, but attempts to withdraw it through the 18F sheath were unsuccessful due to resistance at the distal tip of the sheath. Subsequently, the proximal portion of the balloon catheter was partially detached and removed.An exchange was made to a 22F Gore DrySeal sheath, but again, efforts to withdraw the ruptured balloon were unsuccessful (Figure 1). Various snares were employed, but all attempts to manipulate the balloon into the sheath were ineffective. The ruptured balloon remained in the abdominal aorta and eventually detached from the hypotube.The 22F sheath was then exchanged for a 20F Inari Protrieve sheath. Two Supracore wires were then inserted through the sheath, with one designated for snare delivery and the other for maintaining vessel access. A Tulip snare was guided over one Supracore wire to the descending thoracic aorta, where the snare was opened and the Lunderquist wire was captured at the junction between the stiff and soft parts of the wire (Figure 2). The snared wire and ruptured balloon were retracted into the exposed Nitinol cone of the Inari sheath, successfully engulfing the balloon and compressing it (Figure 3). The sheath, wire, balloon, and snare were then removed as a unit while the wire access was maintained.A new 22F Gore DrySeal sheath was inserted. Inspection confirmed the complete removal of all components of the ruptured True balloon and the catheter. The procedure concluded with the successful deployment of a 29mm Evolut pro CoreValve. The patient made an uneventful recovery and was discharged home the following day.Conclusion:The Inari Protrieve sheath proved valuable in this case of complicated intravascular equipment entrapment. The soft, funnel-shaped nitinol cone aided in capturing and compressing the bulky ruptured balloon, obviating the need for a surgical cutdown.

Circulation, Volume 150, Issue Suppl_1, Page A4141243-A4141243, November 12, 2024. Description of Case:A 36-year-old male with a history of non-ischemic cardiomyopathy status post HeartMate 3 left ventricular assist device (LVAD) presented with a 2-day history of dizziness, lightheadedness, chest pain, and an increase in low flow alarm frequency from his LVAD. On admission, his temperature was 37.2, return to flow was 86, oxygen saturation was 100% on room air, heart rate was 99, and respiratory rate was 23. His lungs were clear to auscultation, and his abdomen was distended, tense, and non-tender. His extremities were warm, with moderate edema in his legs bilaterally. He had mild increased work of breathing without accessory muscle uses. Laboratory evaluation revealed a prothrombin time of 2.6 seconds, a B-type natriuretic peptide level of 176 pg/mL, and a hemoglobin of 13.7 g/dL. Imaging revealed a chest CT demonstrating a complete obstruction of the distal outflow cannula near its attachment to the aorta. Patient hemodynamics worsened after admission, necessitating transfer to the cardiac intensive care unit. After an unsuccessful attempt at warfarin reversal and tissue plasminogen activator administration, the patient was eventually taken for surgical intervention with cardiothoracic surgery. During the procedure, there were no signs of outflow graft thrombus; instead, a sizeable peri-graft fluid collection was observed and drained, which relieved the outflow graft obstruction. The patient’s post-operative course was uneventful, and he was eventually discharged home with a resolution of his symptoms.Discussion:This patient’s presentation presents a few key features that suggest an alternative cause of an outflow obstruction other than an acute thrombus. The most important feature is that the patient had been diligent with his anticoagulation to indicate his being a therapeutic prothrombin time on admission, consistent with the patient’s reported anticoagulation adherence. We believe that cases such as this one provide clinical support for the reevaluation of the way we approach outflow tract obstructions in LVADs; especially as we continue to develop devices that have lower thrombus risk that their predecessors. We hope that this patient’s clinical presentation and course will be helpful in the future differentiation of intrinsic vs extrinsic compression of LVAD cannulas and the management of such obstructions.

Circulation, Volume 150, Issue Suppl_1, Page A4143915-A4143915, November 12, 2024. Case description:A 68-year-old man with history of prostate cancer, anal and scrotal squamous cell carcinoma presented to the cardiology clinic with dyspnea on exertion with exercise tolerance limited to 2 flights of stairs. Physical examination showed grade 3/6 holosystolic murmur best heard at the left lower sternal edge. A transthoracic echocardiograph (TTE) revealed an ejection fraction of 65%, prominent muscle bound right ventricular outflow tract obstruction (RVOT) consistent with double chambered right ventricle (DCRV), and a Windsock deformity of the membranous interventricular septum through which there was a VSD with left to right shunting. The maximal pressure gradient across the VSD was approximately 116mmHg. The pulmonary artery systolic pressure was 61mmHg; consistent with severe pulmonary artery hypertension.Discussion:DCRV is a rare condition accounting for 0.5 to 2% of congenital heart diseases. It is characterized by abnormal muscle bands that divide the right ventricle into two chambers; a proximal high-pressure and distal low-pressure chamber, leading to progressive right ventricular outflow tract obstruction (RVOT). This condition rarely occurs in isolation and is often ventricular septal defect (VSD), which is seen in up to 90% of DCRV cases. DCRV may go undiagnosed until adulthood. As the degree of RVOT increases, patients present with shortness of breath and decreased exercise tolerance. TTE is an invaluable tool for diagnosing and determining the severity of obstruction through pulsed and continuous wave doppler to measure the gradient across the hypertrophied muscle bundles. Current guidelines recommend surgery in asymptomatic patients with severe right ventricular obstruction with a pressure gradient greater than 40 mmHg between the proximal and distal compartments within the right ventricle. Even though our patient was mildly symptomatic, his significant pressure gradient of 116 mmHg warrants surgical evaluation.Conclusion:DCRV is a rare and often overlooked congenital heart disease. The patient, despite mild symptoms, exhibited classic features of DCRV and associated VSD, highlighting the potential for this condition to persist undiagnosed into late adulthood. The presence of severe pulmonary hypertension further emphasizes the importance of early detection and ongoing management to prevent severe complications such as heart failure and sudden cardiac death.