Evolution of Echocardiographic Abnormalities Identified in Previously Healthy Individuals Recovering from COVID-19

(1) Background: Although the infection with the SARS-CoV-2 virus affects primarily the lungs, it is well known that associated cardiovascular (CV) complications are important contributors to the increased morbidity and mortality of COVID-19. Thus, in some situations, their diagnosis is overlooked, and during recovery, some patients continue to have symptoms enclosed now in the post-acute COVID-19 syndrome. (2) Methods: In 102 patients, under 55 years old, and without a history of CV diseases, all diagnosed with post-acute COVID-19 syndrome, we assessed by transthoracic echocardiography (TTE) four patterns of abnormalities frequently overlapping each other. Their evolution was followed at 3 and 6 months. (3) Results: In 35 subjects, we assessed impaired left ventricular function (LVF), in 51 increased systolic pulmonary artery pressure, in 66 diastolic dysfunction (DD) with normal LVF, and in 23 pericardial effusion/thickening. All TTE alterations alleviated during the follow-up, the best evolution being observed in patients with pericarditis, and a considerably worse one in those with DD, thus with a reduction in severity (4) Conclusions: In patients with post-acute COVID-19 syndrome, several cardiac abnormalities may be assessed by TTE, most of them alleviating in time. Some of them, especially DD, may persist, raising the presumption of chronic alterations.

A Case of Self-salvation in a Determined Chloroquine Suicide Attempt

This report concerns a young man who attempted suicide by ingesting a cocktail with a lethal dose of chloroquine phosphate and large amounts of diazepam. On presentation, the patient was drowsy, unresponsive and in cardiogenic shock with severely impaired left ventricular function. Active charcoal and vasopressors were administered, and despite his intoxication with diazepam, a high-dose diazepam treatment was initiated in the hospital. It is concluded that diazepam in the cocktail played a vital role in the survival of this patient. With a rise in numbers, every emergency and intensive care physician should be familiar with chloroquine poisoning.

Effective treatment of electrical storm by a wearable cardioverter defibrillator in a patient with severely impaired left ventricular function after myocardial infarction: a case report

Background The implantation of cardioverter defibrillators (ICDs) is an established therapy in the prevention of sudden cardiac death in patients with systolic dysfunction after myocardial infarction. To avoid immediate implantation of an ICD, wearable cardioverter defibrillator vests (WCD) can be used to protect patients against malignant rhythm disorders, while at the same time drug-based heart failure therapy has to be initiated. This drug therapy can improve left ventricular ejection fraction and primary prophylactic cardioverter defibrillator implantation may not be necessary. However, the recent Vest Prevention of Early Sudden Death Trial (VEST) questioned the regular use of the WCD in this setting. Case presentation A 47-year-old Caucasian man with severely impaired left ventricular function early after myocardial infarction was prescribed a WCD as primary prophylaxis to prevent sudden cardiac death. Seven days after the patient was supplied with a WCD, the patient suffered from an electrical storm with recurrent ventricular tachycardia (VT), which was successfully terminated 17 times by the WCD. On coronary angiography, the formerly infarct-related right coronary artery had TIMI (Thrombolysis in Myocardial Ischemia Trial) III flow, and a remaining stenosis in the left anterior descending artery (LAD) was stented, which did not stop recurrent VT. In the electrophysiology (EP) study, a focus was mapped in the left inferior ventricle, which was ablated. This stopped the VT. A second radio-frequency (RF) ablation in the same area was necessary after 14 days. Finally, a permanent cardioverter defibrillator was implanted. Conclusion We report the case of a patient who survived recurrent episodes of VT early after myocardial infarction by effective defibrillation with a WCD. The WCD is a useful device to bridge time until a final decision for implantation of a defibrillator.

Treating the treatment: chemotherapy-induced multi-organ toxicity

A 40-year-old man presented to a local hospital with a 2-day history of dyspnoea having been started on adjuvant chemotherapy consisting of oxaliplatin and capecitabine for mucinous adenocarcinoma of the colon. During his admission, he develops chest pain, worsening shortness of breath, and intermittent dysarthria and disorientation. Investigations reveal severely impaired left ventricular function on echocardiogram, bilateral acute pulmonary embolisms on CT pulmonary angiogragraphy, and diffused subcortical and callosal white matter signal change and restricted diffusion consistent with a toxic leukoencephalopathy on MRI of brain. This case highlights the pivotal role of the multidisciplinary cardio-oncology approach which enabled these challenging diagnoses to be made and ensured optimal patient outcome.

Management of systemic hypotension in term infants with persistent pulmonary hypertension of the newborn: an illustrated review

In persistent pulmonary hypertension of the newborn (PPHN), the ratio of pulmonary vascular resistance to systemic vascular resistance is increased. Extrapulmonary shunts (patent ductus arteriosus and patent foramen value) allow for right-to-left shunting and hypoxaemia. Systemic hypotension can occur in newborns with PPHN due to variety of reasons, such as enhanced peripheral vasodilation, impaired left ventricular function and decreased preload. Systemic hypotension can lead to end organ injury from poor perfusion and hypoxaemia in the newborn with PPHN. Thus, it must be managed swiftly. However, not all newborns with PPHN and systemic hypotension can be managed the same way. Individualised approach based on physiology and echocardiographic findings are necessary to improve perfusion to essential organs. Here we present a review of the physiology and mechanisms of systemic hypotension in PPHN, which can then guide treatment.

Hydroxychloroquine and risk of cardiac decompensation

Background Hydroxychloroquine (HCQ) is a 4-aminoquinoline derivative, used in the treatment of malaria and rheumatic diseases. HCQ has also been suggested as a treatment in patients suffering from severe acute respiratory syndrome–coronavirus 2 (SARS–CoV-2). One of the cardiac complications of SARS-CoV-2 is myocarditis and ventricular dysfunction. Case summary We present the case of a 52 year old lady presenting with 2 months history of breathlessness, found to have severely impaired left ventricular function. She had been taking HCQ for 28 months for seronegative inflammatory arthritis. No cause was identified on initial investigation. She was treated with optimal medical therapy, and HCQ was stopped. After 5 months a cardiac MRI scan revealed full remodelling of the ventricle. Discussion This case highlights one of the lesser recognized side effects of HCQ, and the potential for severe cardiac dysfunction. As this drug continues to be investigated and used in the management of SARS-CoV-2 it is important to recognize the potential for cardiac decompensation in patients who are already at increased risk of myocardial dysfunction.

P1167Effect of diabetes on all-cause mortality in CRT patients

Background Heart failure patients with diabetes mellitus (DM) have a higher risk for all-cause mortality and also for sudden cardiac death. We lack data on the effect of adding an implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy (CRT) on all-cause mortality in diabetic heart failure patients. Purpose We aimed to investigate the risk of DM on all-cause mortality in CRT patients, and to examine the beneficial effect of adding an ICD on all-cause mortality by left ventricular ejection fraction in CRT patients with or without DM. Methods We examined retrospectively 2525 patients who underwent CRT implantation based on the current guidelines at our clinic between June 2000 and September 2018, of which 928 (36%) had diabetes. The primary endpoint was all-cause mortality, also expressed as events per 100 person-year by quintiles of ejection fraction (EF) with or without an ICD or DM. Time to event data was investigated by Kaplan Meier and multivariate Cox regressional analysis. Results During our mean follow-up time of 4.6 years, 1432 (56%) patients reached the primary endpoint, of which 553 (38%) had DM. In the DM group, hypertension (82% vs. 66%; p‹0.01), ischemic etiology (56% vs. 44%; p‹0.01), myocardial infarction (43% vs. 36%; p‹0.01) was more frequent compared to non-DM group. There was no difference between the two groups regarding the implantation of an ICD (54% vs. 53%; p = 0,84). Those with DM showed a 25% higher risk of all-cause mortality (HR 1.25; 95% CI 1.12-1.40; p‹0.01), also observable after adjusting for relevant clinical covariates such as age, gender, atrial fibrillation and the addition of an ICD (HR 1.17; 95% CI 1.06-1.31; p‹0.01). Examined as all-cause mortality per 100 person-year follow up, patients with EF›30% and DM (13,7 events/ 100 person-year follow-up for an EF 30-35%) showed similar risk as those without DM and a severely impaired left ventricular function with EF‹25% (14 events/100 person-year follow-up for an EF <25%). Investigating the composite end-point of all-cause mortality and heart failure hospitalization, those with DM showed a 21% higher risk than non-DM CRT patients (HR 1.21; CI 1.09-1.34; p = 0 < 0.001). Adding an ICD for CRT patients with DM reduces the risk of all-cause mortality significantly by 32% (HR 0,68; CI 0,56 to 0,82; p < 0.001) during the first six years but diminished on longer follow-up time. Conclusions Diabetes was found as an independent predictor of all-cause mortality in CRT patients. Those with a left ventricular ejection fraction above 30% have comparable risk of mortality as non-diabetic patients with a severely impaired left ventricular function. In diabetic CRT patients the addition of an ICD reduces the risk of all-cause mortality mostly seen in the first six years. These findings might implicate the relevance of adding an ICD to CRT even at a higher ejection fraction in those with severe comorbidities such as diabetes. Abstract Figure. All-cause mortality in CRT, DM patients

Postoperative cardiogenic shock secondary to Takotsubo’s syndrome

Takotsubo’s syndrome is a rare acute reversible heart failure, where the pathophysiology is not fully understood. It is being increasingly diagnosed in varied clinical contexts, which can result in atypical presentations in the context of surgical or anaesthetic stress. We discuss the case of a 22-year-old woman who developed cardiogenic shock and impaired left ventricular function after an elective gynaecological procedure. She had a rapid recovery and a follow-up cardiac MRI confirmed Takotsubo’s syndrome.