A case of successful heart transplantation from a donor that suffered an out of hospital cardiac arrest lasting approximately one hour is presented. The recipient, a 27-year-old female nurse, was diagnosed with arrhythmogenic right ventricular cardiomyopathy in 2012. The donor was a 24-year-old male who after consuming an unknown quantity of alcohol and cocaine aboard a yacht was found floating face-down in the sea. The patient to be pulseless and CPR commenced after 7 minutes. The length of time that he spent in the sea was unknown. Return of spontaneous circulation (ROSC) occurred after 20 minutes of CPR on site. However, the patient arrested again in the ambulance and CPR was performed until he arrived Hospital, still in cardiac arrest. The patient arrested three more times before achieving a stable circulation. He was transferred to the intensive care unit on high doses of Noradrenaline and Adrenaline to maintain an adequate mean arterial blood pressure. An initial echocardiogram (ECHO) revealed a hypocontractile left ventricle (LV) with an estimated ejection fraction (EF) of 30%.Over the following 3 days the patient’s cardiac function improved. He was weaned off inotropic support and a repeat ECHO showed a normal LV with an EF of 70%. A brain MRI showed diffuse swelling consistent with global hypoxic injury with wide areas of cortical and basal ganglia infarction. The patient’s parents gave their consent and he was offered for organ transplantation on day 6. The operation was successful, with the recipient making an uneventful recovery. She received immunosuppressive treatment with cyclosporine, prednisolone and azathioprine and experienced one episode of early mild rejection with full resolution. She remains well 8 months later.
BackgroundHypertension not only predispose to cardiovascular diseases, it is also associated with electrolyte imbalances (EIs), which in most cases subtly impacts on morbidity and mortality. We aimed to determine the prevalence and pattern of EI in hospitalized hypertensives from three teaching hospitals in Nigeria.MethodologyThis was a retrospective study of hypertensive patients who were admitted in three teaching hospitals in the cities of Lagos, Kano and Ogbomosho, Nigeria. Medical records and serum electrolyte results done at the point of admission were retrieved and analyzed.Results159 admitted hypertensive patients who had analysis of their electrolytes were recruited of which 106 (66.7%) were males, while 53(33.3%) were females. Majority of patients (138 {86.8%}) had at least one EI, while only 21 (13.2%) had normal electrolytes. 39(24.5%) patients had more than two EIs; 55(34.6%) had two EIs, while 44(27.7%) had one EI. The commonest electrolyte abnormality was hyponatremia seen in 63 (39.6%) patients, followed by hypokalemia, reduced bicarbonate and hypochloremia found in 58 (36.5%), 53(33.3%), and 40 (25.2%) respectively.EI was more prevalent among females (96.2% vs 82.1% in males; p=0.002), patients who had tachycardia (94.3% vs 80.9% of patients without tachycardia; p=0.042) and those with elevated diastolic blood pressure DBP (p=0.034).ConclusionEIs are very common among hospitalized hypertensive patients, with most of them having multiple derangements. EI was more prevalent in females, patients with tachycardia and elevated (DBP).Key words: Hospitalized hypertensive, electrolyte imbalances, Potassium, Sodium, bicarbonate, Chloride.
An attempt to review links of cardiovascular disease (CVD) and depression and present appropriate treatment methods for handling depression in the COVID-19 pandemic is made. Although depression constitutes one of the major mental health challenges that humankind must encounter in the 21st century it remains undiagnosed and untreated in CVD patients. Its great influence on the progress of CVD led to its classification as a risk factor along with dyslipidemia, arterial hypertension, diabetes, obesity, substance use, sedentary lifestyle (poor diet, stress) making imperative the need for treatment methods. As during COVID 19 pandemic we witnessed the elevation of mental distress as involving both lifestyle choices and dealing with unprecedented life situations while inducing psychological distress or exacerbating pre-existing physical and mental health problems – depression could act both as a contributor to and as the result of CVD. A 4-step intervention program is suggested.
Insufficient statistical information on the structure of mortality in the era of the pandemic is disclosed in this article. It analyzes the statistics and the causes of death during the COVID-19 pandemic from a new coronavirus infection and cardiovascular disease. Actual international data on a decrease in the hospitalization rate of patients with acute coronary syndrome are presented. A comparative analysis of statistics from European countries and Russia shows that cardiovascular diseases are the leading cause of death in populations, and patients with cardiovascular diseases are at increased risk for morbidity and mortality during the COVID pandemic.
Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations. Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations.
COVID-19 is highly fatal disease having high mortality rate and is declared as pandemic situation by world health organization. It shows a clear indication that every individual is at risk of this pandemic especially older individual and immunocompromised persons. As its casual agent is SARS-Cov-2 and the main target site of this virus is the ACE2 receptor of lungs. But as compared to lungs ACE2 receptor is highly expressed in other organs i.e. kidney, liver, brain, GI tract, cutaneous, adipose tissues and cardiovascular system these organs are susceptible to COVID-19 infections because of having ACE2 receptor. Many co-infections associated with COVID-19 are reported i.e. neurological manifestation of COVID-19, cutaneous manifestations of COVID-19, endothelial cell infection and endotheliitis, adipose tissues infections, cerebral hemorrhage, liver injury, cardiovascular complications, kidney infection, trigger immune system response and subsequent organ failure. In this review we highlight ACE2 mediated viral entry of the SARS-Cov-2 and subsequent multi organ failure in COVID-19.
Background: The purpose was to develop a novel hypothetical method to increase the size of coronary arteries. Methods: In the long-term observation the coronary sizes were dilated in three unexpected scenarios. The coronary artery sizes were observed in patients with mitral stenosis (n=59) by angiogram prior to percutaneous balloon mitral valvuloplasty or valve replacement surgery for severe mitral stenosis. The coronaries of patients with patent ductus arteriosus who underwent surgical closure in the past (n=12) were examined by echocardiogram. Patients with renal failure on long-term dialysis through peripheral arterio-venous fistula without left ventricular hypertrophy (n=17) were studied by echocardiography. Normal age, weight and sex matched coronary sizes served as controls in the study. All these observations were made over a period of 11.5 years. Results: The sizes of coronaries in patients with mitral stenosis, patients who underwent closure for patent ductus arteriosus, and in patients on hemodialysis through arteriovenous fistulas were higher than normal controls (p<0.05, for all). A hypothetical model to increase the coronary sizes could be developed based on the analysis of the differential equations of Poiseuille’s. The proposed method is creating a peripheral arterio-venous fistula, which could be closed later electively by a percutaneous method/surgery. The closure time needs to be determined by experimental studies. The other methods could be a continuous exercise program or usage of beta-blockers. Conclusion: A novel hypothetical method of peripheral arteriovenous fistula formation could potentially increase the size of the coronaries, and this could be closed later.
Isolated left ventricular (LV) apical hypoplasia is a rare type of congenital heart disease. It is often asymptomatic in childhood but may lead to complications later on in life. The proposed mechanism is inadequate LV dilatation during development of the primitive ventricle, resulting in a spherical LV. To our knowledge, we describe for the first time a case of isolated LV apical hypoplasia in an asymptomatic patient, diagnosed on investigation of an abnormal 12-lead resting electrocardiogram (ECG).
COVID-19 is extremely lethal disease and almost 190 countries is suffering from the latest pandemic. The literature indicates that COVID-19 is more prevalent in patients with compromised immune systems. Patients with cancer are particularly vulnerable to COVID-19 because of immune compromised condition due to immunosuppressive therapy. Immunotherapy results in mixing or overlap of COVID-19 associated pneumonia and immune-related pneumonitis and thus makes the diagnosis process very confusing. On the other side in this pandemic, treating cancer patients in hospital will bring a lot of risk. There is still no strong evidence on the cancer-COVID-19 connection. Yet, in this pandemic, patients with cancer should be treated as special cases. Risk management is highly needed in the critical time of this pandemic. This review highlights the association between COVID-19 and cancer, also the strategy to minimize the risk of COVID-19 in cancer patients.
Background: Peripartum cardiomyopathy (PPCM) is common in North-West Nigeria and many affected patients have selenium deficiency. It is not known whether asymptomatic cardiac dysfunction related to selenium deficiency commonly starts during pregnancy in the region. The study aimed to determine the prevalence of left ventricular (LV) systolic and diastolic dysin apparently healthy pregnant women and if there is relationship with serum selenium, in a society with high prevalence of PPCM. Methods: This was a prospective longitudinal study carried out in 3 centers in Kano, Nigeria. 108 apparently healthy pregnant women were consecutively recruited between the 28th and 38th weeks of gestation and reevaluated at the 6th to 8th weeks postpartum. Serum selenium was measured at enrolment during pregnancy. LV systolic dysfunction was defined as LV ejection fraction (LVEF) below 50% and LV diastolic dysfunction was defined and graded according to the recommendations of the American Society of Echocardiography. Results: LV systolic dysfunction and diastolic dysfunction were found in 6 subjects (5.6%) and 20 subjects (18.5%) during pregnancy, and in 9 subjects (10.2%; p=0.340) and 14 (15.9%; p=0.631) of them after delivery, respectively. Mean LVEF was 62.2±6.9% and 60.6±8.2% (p=0.108) during pregnancy and after delivery respectively. Mean LV end-diastolic dimension measured during pregnancy (48.6±4.9 mm) was not significantly difference with what was obtained after delivery (47.2±6.9 mm) (p=0.099). Mean left atrial size (37.0±4.8 mm vs. 35.2±4.8 mm; p<00.1) and mitral septal E/e’ ratio (8.4±2.8 vs. 1.3±0.5; p<0.001) were higher during pregnancy than after delivery, respectively. Selenium deficiency (<70 μg/L) was found in only 2.8% of subjects, and serum selenium did not significantly correlate with indices for LVEF or diastolic (mitral E/e’ ratio) functions both during pregnancy and after delivery. Conclusions: LV systolic and diastolic dysfunction and selenium deficiency were uncommon during apparently healthy pregnancy and early puerperium, and serum selenium did not correlate with indices for LV function, in a population with high prevalence of PPCM.
Background: Transfusion is common after coronary bypass surgery. Transfused patients present with higher operative risk and increased hazard ratio for curtailed long-term survival. There is debate as to whether transfusion itself may further exacerbate late mortality. Methods: Long-term survival was studied in 2550 survivors following coronary revascularization in this retrospective, observational study. Kaplan-Meier survival curves were constructed to compare all transfused and non-transfused patients, as well as survival in propensity-matched transfused and non-transfused patients. Results: Operative mortality was 1.05% (original cohort 2577). Maximum follow-up was 23 years (mean 11.8, median 12.4 years). 34.7% of patients received a transfusion (mean 2 units pack red blood cells). Baseline risk characteristics (age, female gender, small body habitus, risk stratification scoring, diabetes, hypertension and reduced stroke volume) operative parameters (urgency and no internal thoracic graft) as well as post-operative parameters (intensive care, hospital stay and ventilation time) and complications (haemorrhage, intra-aortic balloon, ventricular arrhythmias, prolonged inotropic support, atrial fibrillation, dialysis, doubling of creatinine and resternotomy) were higher in the transfused patients. The long-term survival of these patients was significantly reduced when compared with that of non-transfused patients (log rank test p<0.001). When analyzed as a sole risk factor, transfusion was associated with reduced long-term survival (log rank test p<0.001) but when analyzed collectively with other risk factors, transfusion failed to demonstrate a causative effect (p=0.953). When propensity matched groups were compared (612 transfused versus 1222 non-transfused patients) long-term survival was similar (log rank test p=0.554). Conclusions: Transfusion was required in higher risk patients undergoing coronary revascularization. Long-term survival was curtailed in this group but this was due to preoperative risk and not directly to transfusion. Transfusion was a predictor but not a cause of reduced long-term survival.
PURPOSE: Patients suffering from an acute coronary syndrome are at very high risk for recurrent events. Early targeted pharmacological intervention primarily aimed at controlling plasma LDL-cholesterol (LDL-C) levels can result in the reduction of recurrent cardiovascular events. This study aimed to evaluate real-life evidence from the Italian setting to document current practice of secondary prevention in patients after acute coronary syndrome (ACS), specifically assessing: (i) the rate of LDL-C target (<70 mg/dl) achievement after 6-10 weeks from index event and at later follow-up, (ii) the distance from LDL-C target during follow up, (iii) adherence rate and visit attendance. METHODS Multicenter observational prospective clinical study ACS patients, evaluating target attainment rate at 6 weeks (V0) and 18 months (V2). RESULTS Approximately 97.4% patients enrolled (N=524) received statin-based therapy, and 3.6% received ezetimibe at discharge; mean LDL-C values decreased from 113.0±44.7 mg/dL at discharge to 71.3±26.5 mg/dl at V0. Among patients with known LDL-C for main time-points, 51.7% achieved target LDL-C at V0, 45.8% at V2. Among patients not reaching the target, the mean distance from target was 23.5±20.7 mg/dL. Attainment of target LDL-C was similar in patients receiving intensive or low-moderate statin-based treatment (approximately 50%). LDL-C target attainment was associated with lower LDL-C value at discharge and smoking status. Adherence to statin treatment was high (96.2%) throughout, similarly to medical appointment attendance at V2 (84.7%). CONCLUSION Despite most ACS patients receiving intensive statin-based regimens, only approximately half achieved LDL-C target, suggesting the need for further optimizing drug selection, combination and dosage.
Background: The Impella® devices have increasingly become a desired treatment option for cardiogenic shock (CS) as demonstrated by studies analyzing real-world use of hemodynamic support devices. However, data regarding outcomes after Impella® device implant and optimal timing of device placement remains scarce. This study investigates prognostic factors including serial lactate levels in CS patients treated with Impella®.Methods: This retrospective study reviewed 76 consecutive patients diagnosed with CS supported with Impella® at a large, tertiary-care university medical center. Clinical variables and outcomes examined include co-morbidities, pre- and post-procedural lactate levels, and mortality.Results: Of the 76 patients requiring an Impella®, 70% of patients survived to hospital discharge. Those who died post-device implant had a higher prevalence of hyperlipidemia (HLD), chronic kidney disease (CKD), and more likely to require multiple (>1) vasopressors. The mean pre-procedural lactate levels were significantly higher (5.86 +/- 5.11 vs 2.16 +/- 1.50, p = 0.01) in the population who died, along with the change in lactate levels (1.90 +/- 2.56 vs -0.40 +/- 1.73, p=0.04). Those who died within 24 hours of implant showed a trend toward higher mean pre-procedural lactate levels (8.46 +/- 6.00 vs 3.86 +/- 3.31, p = 0.12).Conclusions : Higher pre-procedural lactate levels, HLD, CKD, and increased vasopressor requirement were predictive of increased mortality in CS patients post-Impella® placement, especially within 24 hours of implant. Through serial lactate measurements, we demonstrated favorable outcomes in patients with early stabilization or greater lowering of post-procedural lactate levels suggestive of improved end organ perfusion.
The VICTORIA trial showed Vericiguat once daily (titrated up to 10 mg) significantly reduced its primary end-point, the composite of death from cardiovascular causes or first hospitalization for heart failure, in 5050 class II-IV HFrEF patients (LVEF<45%). This a land-mark trial, one of the largest we have seen in heart failure, and it had some very important novel features; it only recruited patients with a recent (within 6 months) worsening of their heart failure, a group known to be at increased risk of subsequent events, and it included more severe heart failure than most recent trials with NTproBNP levels nearly twice that of Paradigm-HF or DAPA-HF. VICTORIA had substantially higher mortality rate but an apparently less impressive hazard ratio (HR) 0.90 (0.82 – 0.98) compared to Paradigm’s 0.80 (0.73 – 0.87) and DAPA’s 0.74 (0.65 –0.85). This must be considered against a healthy absolute risk reduction at 4.2% compared to Paradigm’s 2.7% and DAPA’s 4.0%, due to the higher risk patients in VICTORIA. Another very important difference with VICTORIA is that it included the higher risk recently discharged HF patients, and patients eGFR’s down to 15 ml per minute per 1.73 m2 of body-surface area, possibly suggesting a special place for Vericiguat in traetring these at-risk subsets of HFrEF patients, but for the fact that the cohort between 15 and 30mL/min/1.73m2 of eGFR was only around 10.0%, and the point estimate for the HR for this small group was above 1.0 at 1.06 (0.83-1.34). Aslo the sub-grouping by NTproBNP level was highly significantly interacting (p<0.001) with the lower three quartiles all being significantly in favour of Vericiguat and the highest quartile (>5,314 pg/mL) being almost significantly worse on Vericiguat with a HR of 1.16 (0.99-1.35). So the two major areas where Vericiguat may have received special notice appear to be less impressive when we look in detail at the trial results. How do we therefore place Vericiguat in the wake of VICTORIA? It is a proven therapy in a disease which still has residual high rates of clinical mortality and morbidity. It conveyed a benefit on top of other therapies, thus it should be not ignored and may indeed be a very effective therapy in some patients.
The burden of cardiovascular disease in developed countries has shown dramatic improvements over the last 50 years, largely due the identification and control of major risk factors including, smoking hypertension and high cholesterol. However, due to the significant increase in obesity and diabetes CVD incidence rates will not reduce as far over over the next years. Risk prediction in asymptomatic individuals remains a major challenge. Primary preventive treatment is currently based on the assessment of individual’s global risk mainly through screening of conventional risk factors and their treatment with lifestyle intervention and pharmacotherapy, often based on multivariate risk equations, and yet a large proportion of CVD still occurs in individuals who are classified as carrying low- or intermediate-risk according to the risk scores. Atherosclerosis is the most common pathophysiologic process underlying CVD, often after a prolonged asymptomatic phase during which it may be possible to modify the course of the disease. Unlike conventional probabilistic risk scores, non-invasive imaging techniques such as carotid intima-media thickness (CIMT) along with plaque assessment (Figure 2), measured by B-mode ultrasound, and coronary calcium scoring (CAC) detected by CT scan have the advantage of direct visualization of the consequences of atherosclerosis on the arterial system. We consider the proposal that imaging of subclinical atherosclerosis is superior to risk equations as it directly identifies the disease and can effectively predict the risk of future CV events in low- and intermediate-risk individuals. In addition, imaging can improve the adherence to guidelines based treatment in patients and their physicians.
Highlights: Left ventricular pseudoaneurysms are a rare mechanical complication of myocardial infarction. If found acutely following infarction (within 2 weeks, with some advocating up to 3 months), surgical repair is recommended due to their high risk of rupture.Whilst associated with chest pain, dyspnoea and heart failure, some individuals are asymptomatic, with the diagnosis made incidentally on routine follow-up often months to years post infarction. Less is known about the natural history of these chronic pseudoaneurysms, with concerns around their propensity to rupture perhaps less than the mortality risk of surgical repair.We present the case of a 70 year-old asymptomatic man who was found to have a 1.6cm left ventricular pseudoaneurysm found incidentally on routine transthoracic echocardiogram at 12-months post posterior myocardial infarction.The consensus opinion of our institution's multi-disciplinary team regarding further management of this patient, with reference to the current limited data on chronic pseudoaneurysms, will be discussed.
The novel coronavirus outbreak arose in Wuhan, China in Dec, 2019. It is declared the 6th public health emergency by the WHO and named as COVID-19. SARS-CoV-2 is nonsegmented positive sense ssRNA virus, belongs to the Coronaviridae under the Nidovirales and spread largely in human being and other mammals. Person to person, airborne and surface transmission is common, the virus get entered to host through nose, mouth, eyes, food, water and feces. An infected patients can transmit the virus to 2.2 healthy individuals. A patient in the US showed gastrointestinal symptoms vomiting, nausea and pass loose stools. Later the patient declared positive for SARS-CoV2 on the basis of viral detection in stools and respiratory samples. The gastrointestinal symptoms like diarrhea, nausea, vomiting, abdominal discomfort and detection of SARS-CoV-2 in stools of infected and recovered patients indicates potential oral fecal transmission route, it could be a potential risk for the spread of COVID-19. The flatus is gas produced by aerophagia or bacterial fermentation in intestine and expelled out through esophagus or anus. It comprises Hydrogen, Oxygen, Nitrogen, Carbon dioxide and Methane, their percentage composition is 99%. Previous study showed that bacteria can transmit through bare bottom farting. The gastrointestinal manifestation and possible oral-fecal transmission, the flatulence could be the risk of transmission for COVID-19. We must adapt personal hygiene to prevent the spread of disease.
A novel coronavirus causing Acute Respiratory Distress Syndrome (SARS-CoV-2) has been considered the cause of a large number of lower respiratory tract infections leading to severe respiratory failure in many cases. However, the evidence-based hospital reports show that the COVID -19 infestation may range from an asymptomatic or minimally symptomatic course with an almost bizarre deterioration of life parameters (“silent hypoxia”) through to critically ill patients with multiple organ failure including that of the lungs, kidneys, nervous system and other organs. Moreover, this coronavirus disease may cause significant lung damage in asymptomatic COVID-19 positive patients who recover at home.The virus enters through the angiotensin-converting enzyme 2 receptor (ACE2) widely expressed in the cardiovascular system and other organs and tissues, which can result in myocardial injury, myocarditis, acute myocardial infarction, heart failure, arrhythmias, brain stroke, acute pleuritis, pneumonia and venous thromboembolic events. COVID -19 - induced failure of some central mechanisms controlling breathing and the circulation may explain the mismatch between the clinical symptoms and the objective physiologic life parameters in many patients treated by intensivists or cardiologists. The severity of coronavirus disease is dependent on numerous factors including the magnitude of the host immune response, the impairment of central and peripheral nervous system, age, co-morbidities (e.g. diabetes, arterial hypertension, obesity, chronic heart failure) and presumably genetic proclivity. A brand-new treatment approach with use of alternative or experimental therapies such us Extracorporeal Membrane Oxygenation (ECMO), plasmapheresis, proinflammatory interleukins - targeted drugs, covalescent plasma transfusion, virus replication inhibitors is obviously needed in some COVID-19 patients.
This case study investigates the heart rate (HR) and heart rate variability (HRV) in a patient with coronavirus disease 2019 (COVID-19). We report the case of a 58-year old male who contracted COVID-19. During his disease, 24-hour Holter electrocardiography (ECG) was performed continuously. For comparison, his 24-hour Holter ECGs from the previous 10 years were available. In this patient, COVID-19 was associated with a decrease in HR and a paradoxical decline in HRV. An abrupt decline in HRV and a decrease in HR may signal the onset of COVID-19 before common symptoms such as dry cough or fever appear. In addition, HRV and HR measurements may help to evaluate the course of the disease.
The role and adverse effects of mineralocorticoid receptor overactivation in the pathophysiology of heart failure (HF) is well-recognised. MR antagonists (MRAs) have been tested in HF and shown to be effective in improving outcomes. Steroid-type MRAs spironolactone and eplerenone, have been proven to reduce mortality in HFrEF. In patients with HFpEF, the TOPCAT trial found no significant benefits of spironolactone on cardiovascular outcomes. In order to overcome the limitations of existing steroidal MRAs, novel MRAs have been recently developed, finerenone and PF-03882845.
