INTRODUCTION:Renal cell carcinoma (RCC) is a common malignancy known for its potential to invade the venous system, particularly the inferior vena cava (IVC), leading to tumor thrombus (TT) formation. While the presence of TT in RCC isn't unique, extension of TT above the diaphragm is rare. This case highlights the challenges encountered in diagnosing and managing RCC with extensive TT involvement. CASE REPORT:A 69-year-old man presents with 3-month history of dyspnea and increasing fatigue in the setting of 30 pounds weight loss. Laboratory studies showed anemia and acute kidney injury. CT abdomen and pelvis revealed 6.8cm solid mass within the left perinephric space, enlarged IVC with large thrombus. Kidney biopsy returned positive for clear cell renal carcinoma with metastasis to the liver. Several days into the hospitalization the patient began to experience increased abdominal pain. Repeat ultrasound showed tumor thrombus with extension within the intrahepatic IVC and hepatic veins and reversal of portal venous flow. During the imaging study, the patient suffered a cardiac arrest and expired. Postmortem examination revealed diffuse showering of tumor emboli within the pulmonary arteries, likely contributing to the patient's rapidly progressive respiratory failure, and subsequent cardiovascular collapse. CONCLUSION:This case illustrates the complexity of treating patients with extensive TT. In patients with RCC associated TT, the risk for thromboembolism is increased substantially, however the full benefit of anticoagulation remains controversial. Understanding the intricacies of TT involvement and its potential complications is crucial in guiding treatment decisions in patients with significant tumor thrombus burden.

Introduction: Pericarditis is an inflammation of the pericardium, a thin sac-like membrane surrounding the heart, which can progress to life threatening cardiac tamponade. It can be caused by infections (viral, bacterial, fungal, or parasitic), autoimmune conditions, injuries, or underlying medical conditions. Common symptoms include chest pain, fever, shortness of breath, and fatigue. In the case presented, the patient suffered from a severe form of pericarditis caused by a rare infectious etiology, leading to the development of cardiac tamponade. Case Summary: A 29-year-old female with type II diabetes and hypothyroidism presented with a week of shortness of breath, chest pain, lightheadedness, and loss of consciousness. Workup showed WBC (20.6), CRP (283), and ESR (85). Echocardiogram revealed a large pericardial effusion with right ventricular collapse, indicating cardiac tamponade. She underwent pericardiocentesis, draining 400 ml of exudative fluid. Unfortunately, the effusion rapidly re-accumulated, requiring a pericardial window procedure with drainage of fibrinous, loculated fluid over 2 days, improving her symptoms. She was discharged on colchicine and NSAIDs, however she returned 5 days later with recurrent symptoms and fever. The culture of the previous fluid showed Cutibacterium acne. Histopathology of pericardial biopsy revealed fibrinoid pericarditis. She was treated with ceftriaxone, and transitioned to doxycycline for 14 days, along with 14 days of ibuprofen and 3 months of colchicine. At 3-month follow-up, she was asymptomatic with no effusion recurrence. Conclusion:: As bacterial pericarditis cases rise, the initial work-up should include investigating bacterial etiology. This raises the question of antibiotic coverage for patients presenting with pericardial effusion until bacterial etiology is excluded and also advocate for elective pericardiocentesis in bacterial effusions without tamponade physiology.

Introduction: Atrial remodeling in HFpEF typically results in impaired ventricular diastolic function, and the maintenance of sinus rhythm would be key to improve clinical outcomes in these patients. The CABANA trial provides limited evidence for the benefits of AF ablation in HFpEF patients. While observational studies suggest otherwise, the results of upcoming RCTs like AMPERE and CABA-HFPEF may offer deeper insights. Objective: This study examines the inpatient outcomes of hospitalized HFpEF patients with AF who underwent catheter ablation Methods: A retrospective analysis of a nationwide inpatient database from 2017 to 2019 was conducted. The study included patients diagnosed with both HFpEF and AF. A propensity score-matched cohort compared HFpEF and AF patients who underwent catheter ablation with those who did not. Results: Among 8.2 million HFpEF patients, 2.6 million had AF, and 24,015 underwent catheter ablation. Mortality was significantly lower in the ablation group compared to the control group (4.6% vs. 1.7% in unmatched cohort, 3.8% vs. 1.7% in matched cohort). The adjusted hazard ratio for mortality was 0.43 (95% CI: 0.34-0.55, p<0.00), indicating a 57% lower risk of death in the ablation group. Conclusion: Catheter ablation may offer mortality benefits for HFpEF patients with AF, as suggested by this study. This could foreshadow the findings of ongoing trials like AMPERE and CABA-HFPEF, indicating that ablation could be a valuable treatment option for this high-risk patient group not responding well to standard therapies.

INTRODUCTION: Right ventricle perforation is a serious complication of intravenous permanent pacemaker (PPM) lead implantation, with cardiac tamponade being the most severe manifestation.Here, we present an unusual case following PPM lead implantation.CASE PRESENTATION: A 78-year-old male with a medical history of coronary artery disease, atrial fibrillation, congestive heart failure, and hypertension underwent dual-chamber PPM placement for sick sinus syndrome.On the seventh day postimplantation, he became tachycardic and hypotensive.Serial echocardiograms revealed a small to moderate pericardial effusion with a small hypoechoic mass on the anterior right ventricular (RV) wall (Figure 1, arrow).Urgent chest computed tomography (CT) showed the pacemaker lead positioned inside the RV chamber (Figure 2).The following day, due to refractory hemodynamic instability, dynamic ST elevations, and an enlarged pericardial effusion, the patient underwent emergent surgical pericardial effusion drainage through a subxiphoid pericardial window.His blood pressure initially improved as an intraoperative transesophageal echocardiogram confirmed complete pericardial effusion resolution.However, venous blood-appearing fluid continued to be drained, and he subsequently developed cardiac arrest with pulseless electrical activity.Chest compression, fluid resuscitation, and blood transfusions were started, leading to a return of spontaneous circulation.The surgery was converted to a sternotomy.Pulsatile blood ejection with each heart contraction was observed from a small perforation in the middle anterior wall of RV, which was suture-sealed.Post-operatively, the patient was hemodynamically stable but remained comatose, and unfortunately, his neurocognitive recovery was poor.His family elected comfort care, and he expired after palliative extubation.DISCUSSION: From a retrospective view, the hypoechoic mass in the anterior ventricular wall likely represented a thrombus formed at the perforation site.During the pericardial window drainage, rapid pericardial decompression created a sudden pressure gradient across the RV wall.It was unclear whether the thrombus provided a hemostatic effect or whether its dislodgement during the above pathophysiologic process contributed to the rebleed.As a bare minimum, this echocardiographic finding could help characterize the pericardial effusion as hemorrhagic, suggesting possible ventricular wall perforation.Cardiac tamponade complicates 0.085% to 0.35% (1,2) of cardiac device implantations with intraventricular leads such as PPM and implantable cardioverter-defibrillator.Risk factors include female sex, chronic liver disease, dual-chamber PPM, (1) and anticoagulation.(2) Hypertension and atrial fibrillation were associated with lower odds of tamponade, which were biologically plausible given their correlation to cardiac chamber hypertrophy and fibrosis.Chest pain is the most common symptom (2,3) among manifestations such as syncope, dyspnea, and fatigue.CT is the imaging modality of choice in diagnosing cardiac perforation and has an accuracy of 92.9%.(3) No management guidelines or consensus exist, with treatment options dependent on case specifics.Conservative medical therapy, transvenous lead extraction, (3) and lead replacement under fluoroscopic guidance have been reported successful in managing clinically stable patients.Hemodynamic instability warrants emergent percutaneous or surgical drainage. CONCLUSIONS:We describe unique echocardiographic findings of thrombus likely on a ventricular free wall perforation.Characterizing pericardial fluid helps identify possible perforation and dictates further management of cardiac tamponade post-PPM placement.

Introduction: Arrhythmias are a common cardiovascular manifestation of idiopathic pulmonary fibrosis (IPF), however, associated costs and hospital outcomes are unknown. We aim to determine the impact of cardiac arrhythmias on outcomes and costs among hospitalized IPF patients. Methods: A retrospective cohort analysis was conducted using the National Inpatient Sample from 2017-2019. IPF-associated hospitalizations with and without concurrent arrhythmia were compared and identified by appropriate ICD-10 CM codes. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were the duration of hospitalization and associated costs. Results: Among 92,125 IPF patients, 28.5% (n=26,235) were diagnosed with 29,885 arrhythmias. The most frequent (65%) form of arrhythmias was atrial tachyarrhythmias of which atrial fibrillation was the most predominant (88%). The frequency of bradyarrhythmias, ventricular tachyarrhythmias, and unspecified arrhythmias were 10%, 8%, and 17%, respectively. The IPF-arrhythmia group was predominantly male (64% vs 36%, P < 0.001) and significantly older (76 vs 69 years, p<0.001) with a higher number of comorbidities (3 or more Charlson comorbidity index score: 52% vs 40%, p<0.001). All-cause mortality was significantly higher in the IPF-arrhythmia cohort (12.3% vs. 9.5%, p<0.001) and the odds of in-hospital death remained significantly higher among the IPF-arrhythmia cohort after adjusting for sociodemographic and hospital-level factors (AOR 1.30, 95% CI 1.17-1.44, P <0.001). The hospital length of stay was longer (8.4 vs. 6.7 days, p<0.001), and costs were higher ($123,185 vs. $88,073, p<0.001) among the IPF-arrhythmia cohort. Conclusions: Concurrent arrhythmias are associated with worse survival outcomes and costs for patients with IPF. Future studies are needed to confirm the benefits of treatment and elucidate the appropriateness and cost-effectiveness of screening for arrhythmias among IPF patients.

Introduction: Atrial flutter is one of humans' most common cardiac arrhythmias. Catheter ablation is the definitive treatment for typical atrial flutter because of a very high success (>95%) and low complication rate. Therefore, we explored variations in the use of catheter ablation for atrial flutter among US adults. Methods: We used the 2017-2019 National Inpatient Sample (NIS) for this analysis. Multivariable logistic regression analysis was used to assess factors associated with catheter ablation among patients with atrial flutter in the US. Results: Of the 1406220 adults hospitalized with a diagnosis of atrial flutter, 66825 (4.75%) underwent ablation for atrial flutter. Blacks were less likely to undergo ablation for atrial flutter compared to Whites (AOR=0.91; 95% CI: 0.85-0.99, P = 0.01). Similarly, patients with Medicare (AOR=0.88; 95% CI: 0.83-0.92, P=0.00), and Medicaid insurance (AOR=0.80; 95% CI: 0.74-0.87, P=0.00) were less likely to have catheter ablation for aflutter compared to those with private insurance. Other significant predictors of the likelihood of getting an ablation included younger age 0.98 (95% CI: 0.97-0.98, P=0.00), and lower co-morbidity burden ( class II with AOR of 0.65; 95% CI: 0.62-0.69 and Class III with AOR of 0.43; 95% CI: 0.41-0.46 compared to class I). No gender disparity was observed in this analysis, females had an AOR of 0.96 (95% CI: 0.92-1.00) Conclusions: Findings highlight significant racial and insurance-related disparities in access to catheter ablation for atrial flutter. Addressing social and structural issues underlying these disparities is critical for achieving equitable outcomes for patients with atrial flutter.

Introduction: Transthyretin amyloid cardiomyopathy (ATTR) is thought to be a rare cause of HF, but recent studies showed this is the cause of 30% of HFpEF patients older than 75. With new treatments for amyloidosis, timely diagnosis has become critical. Case: A 78-female with HFpEF, HTN, and diabetes followed for progressive functional decline and hospitalizations for HFpEF exacerbations. EKG at baseline showed LBBB with normal QRS voltages. Serial echocardiogram (echo) showed an ejection fraction (EF) of 60-70%, mild LVH, and moderate TR with RVSP >50 mmHg. Latest echo showed progressive LA enlargement, MR, a new small pericardial effusion, and EF 50%. Regadenoson nuclear scan showed normal perfusion with preserved LVEF. Despite adequate control of her HTN, dyspnea continued to worsen. Because of this, the diagnosis of Cardiac amyloidosis was considered. Further review revealed a history of Carpal Tunnel Syndrome (CTS) and speckled pattern within the ventricular wall on echo. A technetium pyrophosphate scintigraphy ( 99m Tc-PYP) confirmed ATTR with grade three uptake, AL amyloid was ruled out with normal SPEP/UPEP, and she was started on Tafamidis. Discussion: Cardiac amyloidosis should be considered in HFpEF patients with functional decline despite medical optimization. It can mimic LVH caused by HTN on echo and easily dismissed in patients with traditional risk factors, but presence of CTS or lumbar spinal stenosis can be supportive. Traditionally ATTR is associated with low-voltage EKG, however this patient presented with normal QRS voltages for years, making the diagnosis more elusive. Conclusion: Advances in noninvasive imaging and treatments allow for early diagnosis of cardiac amyloidosis, reducing morbidity and mortality. Diagnosis is often delayed or missed, as features could be subtle and mimic other more common cardiac disease. Screening  99m Tc-PYP for elderly patients with HFpEF could translate to improved outcomes

Introduction: Recent estimates of COVID-19 in the US include over 84 million cases with over 1 million deaths. The association between new-onset atrial fibrillation (AF) and COVID-19 has been reported, but hospital outcomes has not been studied among COVID-19 patients with AF. Hypothesis: AF among COVID-19 hospitalizations is not associated with higher rates of adverse in-hospital outcomes. Methods: Using data from the 2020 California State Inpatient Database, we conducted a retrospective analysis of all hospitalized COVID-19 patients ≥18 years of age. Primary outcomes were: prolonged length of stay (LOS) [defined as LOS ≥75th percentile of the population], ICU admission, mechanical ventilation, vasopressor use, and in-hospital mortality. We examined the differences in adverse hospital outcomes among those with AF versus those without. Multivariate logistic regression analyses were used to estimate the association between AF and outcomes after adjusting for cofactors. Results: Our analysis had a total of 94,114 COVID-19 hospitalizations and 9,391 (10.0%) had AF. Adverse hospital outcomes such as prolonged LOS (40.0% versus 27.1%, P <0.001), ICU admission (18.4% versus 8.8%, P <0.001), mechanical ventilation (19.0% versus 9.1%, P <0.001), vasopressor use (4.4% versus 1.9%, P <0.001), and mortality (27.2% versus 9.6%, P <0.001) were significantly higher among COVID-19 hospitalizations with AF. The adjusted odds ratio (aOR) of adverse outcomes such as prolonged LOS (aOR, 1.37, 95% CI: 1.31-1.44), ICU admission (aOR, 2.01, 95% CI: 1.88-2.15), mechanical ventilation (aOR, 1.95, 95% CI: 1.72-2.20), vasopressor use (aOR, 1.98, 95% CI: 1.86-2.11), and mortality (aOR, 2.04, 95% CI: 1.92-2.16) were statistically significantly higher among COVID-19 hospitalizations with AF compared to those without AF. Conclusions: In 2020, AF occurred in about 10% of COVID-19 hospitalizations in California, USA, and was associated with significantly greater risk of adverse hospital outcomes and mortality. COVID-19 patients should be closely monitored for development of AF, and promptly managed like contemporary AF. More studies are however needed to understand the best approach to managing AF in COVID-19 patients.

Introduction: Peripartum cardiomyopathy (PPCM) is a heterogeneous disorder whose pathophysiology remains poorly understood. To better understand the heterogeneity of PPCM, we used latent class analysis (LCA) to explore the different clinical phenotypes in a large sample of PPCM patients. Methods: Using the National Inpatient Sample (NIS) database, we identified 917 patients admitted to hospitals in 2017-2019 with a primary diagnosis of PPCM. We performed LCA based on 8 risk factors: age (< 30 vs > 30), race (African American (AA) vs non-AA), hypertension in pregnancy (HIP) (preeclampsia, gestational hypertension, or chronic hypertension), diabetes mellitus (DM), obesity, tobacco use, cannabis use, and psychiatric disorders (anxiety, depressive, bipolar, or schizophrenia spectrum disorders). We then compared in-hospital outcomes among the different clusters identified by LCA. Data were analyzed using Stata version 17 for descriptive analysis and Mplus version 8.8 for LCA. Results: Four patient clusters were identified. C1 (n=471, 51.4%) had no AA or cannabis users and members had the lowest probability of having HIP (0.387), DM (0.27), and obesity (0.17). C2 (n=328, 35.8%) were all AA who did not use cannabis and had the lowest probability of using tobacco (0.076), and having psychiatric disorders (0.084). C3 (n=31, 3.4%) was the youngest group all of whom used tobacco and cannabis and had the largest probability of having psychiatric disorders (0.484). On the other hand, C4 (n=87, 9.5%) was the oldest group none of whom used cannabis but members had the highest probability being obese (0.664), having HIP (0.825), and DM (0.642). Among all clusters, C3 had the lowest in-hospital mortality (0.0%) and hospital charges ($57,357). C4 had the highest in-hospital mortality 1.1% and longest hospital length of stay (5.4 ± 7.0 days). Conclusions: Using LCA, we identified four clinically distinct classes PPCM with varying in-hospital outcomes. These may reflect different additional underlying mechanisms in PPCM. Our findings may help identify treatment targets and patient selection for future clinical trials.

Background: Arrhythmias are an increasingly recognized comorbid condition among patients with cancers. However, there is little research on the relationship between conduction abnormalities and in-hospital outcomes in patients with myelodysplastic syndrome (MDS). This analysis explores the burden of cardiac arrhythmias and associated outcomes in hospitalized MDS patients. Methods: Nationwide Inpatient Sample from 2017 to 2019 was used. MDS-associated hospitalizations with concurrent arrhythmia were identified using appropriate ICD-10 CM codes and compared to MDS-associated hospitalizations without arrhythmia. Primary outcome was all-cause in-hospital mortality. Secondary outcomes were in-hospital length of stay and total costs. Results: About 21% (n=4065) of MDS patients were diagnosed with an arrhythmia. Atrial tachycardias were most common (87%). Frequency of bradyarrhythmias, ventricular tachycardias, and unspecified arrhythmias were 10.7%, 10.4%, and 0.8%, respectively. The MDS-arrhythmia cohort were significantly older (78 vs 71 years), had higher number of comorbidities (>3 Charlson Comorbidity Index score: 45.5% vs 30%), and were more likely men (57.8% vs 52.7%) (P < 0.001). The MDS-arrhythmia cohort demonstrated higher all-cause mortality (10.6% vs. 5%) and had increased odds of in-hospital death after adjusting for sociodemographic and hospital level factors (AOR 2.2, 95% CI 1.59-2.91) (P < .001). Hospital length of stay (8.5 vs. 8.0 days) and hospital charges ($104267 vs. $105654) were similar across both groups. Conclusions: Concurrent arrhythmias were associated with worse survival outcomes for patients with MDS. Understanding the mortality associated with arrhythmias in MDS patients may have clinical implications when planning treatment options in which cardiotoxicity is an adverse event. Awareness of the frequency and risk factors for arrhythmias in MDS patients may encourage the early introduction of cardiac monitoring for arrhythmias in hospitalized patients with MDS.