A case of coronary artery air embolism in a transplanted heart during cardiac allograft vasculopathy surveillance angiography

Coronary air embolism is a rare iatrogenic complication during invasive coronary angiography or angioplasty that can cause acute chest pain, hypotension, ST-segment elevation myocardial infarction, and even death. We present a case of left anterior descending coronary artery air embolization in a 58-year-old heart transplant patient that occurred during cardiac allograft vasculopathy surveillance angiography. The patient was managed successfully with rapid coronary injections of heparinized saline, catheter disengagement to increase coronary blood flow, and supplementation of 100% oxygen to dissolve the coronary air embolus. This case highlights this rare complication of coronary angiography, importance of prompt recognition of the pathology and subsequent management.

EMPEROR-Preserved: SGLT2 inhibitors breakthrough in the management of heart failure with preserved ejection fraction

Background: Heart failure with preserved ejection fraction (HFpEF) is a complex disease which accounts for more than half of all HF hospital admissions with high prevalence and lack of effective evidence-based management. Sodium-glucose cotransporter 2 (SGLT2) inhibitor is a new antidiabetic drug that recently gained a new role in the management of heart failure with reduced ejection fraction but its role in HFpEF had yet to be studied.Study and results: EMPEROR-Preserved trial set out to evaluate the effects of SGLT2 inhibition with empagliflozin on major heart failure outcomes in patients with HFpEF. The patients were randomized in a 1:1 fashion into two groups; to receive either empagliflozin 10 mg per day (n = 2,997) or placebo (n = 2,991) in addition to usual therapy. Empagliflozin led to a 21% risk reduction of the composite of cardiovascular death or hospitalization for heart failure, which was mainly related to a 29% lower risk of hospitalization for heart failure rather than effect on cardiovascular death empagliflozin. The effects SGLT2 inhibitors were consistent in all patients.

Characterization of morphology and function of the ‘neo-atria’ after a modified Mustard operation

Background: There is a pressing need to improve early and long-term results of the Mustard operation. A modification of the operation was introduced at the Aswan Heart Centre for this purpose which relies on creating new functional atria rather than the two rigid channels in the classical Mustard operation.Objectives: To evaluate the morphology and function of the neo-atria, shortly after modified mustard operation for a ‘neglected’ patient with TGA, VSD and severe pulmonary hypertension.Methods: A 6-year-old with neglected TGA, VSD and pulmonary hypertension presented with severe cyanosis, clubbing and haemoconcentration (Hb 22 g/dL), underwent the modified Aswan-Mustard operation (MAM) with rapid smooth postoperative recovery. Repeated 2D echograms and multi-slice CT scans, followed by 3D segmentation, were performed after the operation. The size, shape, and morphology of the neo-atria were measured and measurements of the patterns of instantaneous filling and emptying of the right and left ventricles were quantified.Results: The neo-systemic venous atrium consisted of three components with a combined volume of 78 mL/m2, all of which contributed to the reservoir, conduit, and importantly contractile function of the neo-atrium. The pulmonary venous atrium consisted of two components with a combined volume of 66 mL/m2. These measurements were made at atrial end diastole. The volumes of the systemic venous and the pulmonary venous diminished to 51 and 54 mL/m2, respectively, at the end atrial systole - indicating relatively preserved contractile functions.

Coronary ectasia due to primary aldosteronism in an exceptional presentation

Primary aldosteronism as a cause of coronary ectasia has been reported only once in the literature and was associated with an aortic aneurysm. Here, we report a second presentation in our cardiology department - a 59-year-old female patient who was admitted for unstable angina. Coronary angiography revealed an ectasia of two major coronary arteries. An etiological assessment revealed an idiopathic primary aldosteronism.

Myocarditis and pericarditis in association with COVID-19 mRNA-vaccination: cases from a regional pharmacovigilance centre

In this article we summarize suspected adverse events following immunization (AEFI) of pericarditis, myocarditis and perimyocarditis that were reported by our regional pharmacovigilance centre after COVID-19 mRNA-vaccination and discuss their association with these vaccines. Seventeen cases were reported between March and July 2021. Of these, nine had perimyocarditis, five myocarditis and three pericarditis. Twelve patients were male (71 %). The median age was 38 years (range 17 - 88). The most commonly observed presenting symptom was acute chest pain (65%). While 47% of the patients were previously healthy, 53% had at least one pre-existing comorbidity, with hypertension being the most prevalent (24%). The European Society of Cardiology diagnostic criteria for the reported AEFIs were fulfilled in twelve cases (71%). The AEFIs occurred after the first vaccine dose in six cases (35%), after the second vaccine dose in ten cases (59%) and after both doses in one case (6%). The median latency of all AEFIs taken together was 14 days (range 1 - 28) after the first vaccination and 3 days (range 1 - 17) after the second one. All patients except one were hospitalized (94%) with a median length of stay of 7.5 days (range 3 - 13). The majority of patients (n = 11, 65%) did not experience any complications, and 13 (77%) of the patients were recovered or recovering at the time of discharge. In 16 of the 17 cases (94%), the association between the AEFI and mRNA-vaccination was considered possible by the pharmacovigilance centre.

CT-based fractional flow reserve: development and expanded application

Computations of fractional flow reserve, based on CT coronary angiography and computational fluid dynamics (CT-based FFR) to assess the severity of coronary artery stenosis, was introduced around a decade ago and is now one of the most successful applications of computational fluid dynamic modelling in clinical practice. Although the mathematical modelling framework behind this approach and the clinical operational model vary, its clinical efficacy has been demonstrated well in general. In this review, technical elements behind CT-based FFR computation are summarised with some key assumptions and challenges. Examples of these challenges include the complexity of the model (such as blood viscosity and vessel wall compliance modelling), whose impact has been debated in the research. Efforts made to address the practical challenge of processing time are also reviewed. Then, further application areas – myocardial bridge, renal stenosis and lower limb stenosis – are discussed along with specific challenges expected in these areas.

Anomalous origin of the left main from the right coronary sinus presenting with sudden cardiac death: utility of mechanical circulatory support

Anomalies involving the origin of the coronary arteries are extremely rare, with the left main artery coronary artery (LMCA) originating from the right coronary sinus (RCS) one of its rarest forms. Anomalous origin of left main from right coronary sinus poses a high risk of sudden cardiac arrest. In our report, we shed light on the case of a 43-year-old female who suffered a witnessed cardiac arrest due to underlying anomalous origin of the left main artery from right coronary sinus. The patient was initially pronounced dead until return of spontaneous rhythm with concomitant myocardial infarction led to the diagnosis of anomalous coronary artery. This case stresses important points to consider when dealing with the acute management and chronic treatment plan for this subset of high-risk patients. We also consider the utility of mechanical circulatory support in management of this condition.

Hypertriglyceridaemia: Contemporary management of a neglected cardiovascular risk factor

Hypertriglyceridaemia represents one of the most prevalent lipid abnormalities, however it is often eclipsed by focus on LDL cholesterol and is frequently overlooked by clinicians, despite it being an important cardiovascular risk factor. For most patients, hypertriglyceridaemia arises from a combination of environmental factors and multiple genetic variations with small effects. Even in cases with apparent familial clustering of hypertriglyceridaemia, a monogenetic cause is rarely identified. Common secondary causes include obesity, uncontrolled diabetes, alcohol, and various commonly used drugs. Correction of these factors, along with lifestyle optimisation, should be prioritised prior to commencing medication.The goal of drug treatment is to reduce the risk of cardiovascular disease in those with moderate hypertriglyceridaemia and the risk of pancreatitis in those with severe hypertriglyceridaemia.Recent and ongoing trials demonstrate the important role of triglycerides (TG) in determining residual risk in patients with cardiovascular disease (CVD) already established on statin therapy. Novel and emerging data on omega-3 fatty acids (high-dose icosapent ethyl) and the selective PPAR modulator pemafibrate are eagerly awaited and may provide further clarity for clinicians in determining which patients will benefit from TG lowering and help inform clinical guidelines. There are numerous novel therapies on the horizon that reduce TG by decreasing the activity of proteins that inhibit lipoprotein lipase such as apolipoprotein C-III (including Volanesorsen which was recently approved in Germany) and ANGPTL 3/4 which may offer promise for the future.

Impact of human immunodeficiency virus on pulmonary vascular disease

With the advent of anti-retroviral therapy, non-AIDS-related comorbidities have increased in people living with HIV. Among these comorbidities, pulmonary hypertension (PH) is one of the most common causes of morbidity and mortality. Although chronic HIV-1 infection is independently associated with the development of pulmonary arterial hypertension, PH in people living with HIV may also be the outcome of various co-morbidities commonly observed in these individuals including chronic obstructive pulmonary disease, left heart disease and co-infections. In addition, the association of these co-morbidities and other risk factors, such as illicit drug use, can exacerbate the development of pulmonary vascular disease. This review will focus on these complex interactions contributing to PH development and exacerbation in HIV patients. We also examine the interactions of HIV proteins, including Nef, Tat, and gp120 in the pulmonary vasculature and how these proteins alter the endothelial and smooth muscle function by transforming them into susceptible PH phenotype. The review also discusses the available infectious and non-infectious animal models to study HIV- associated PAH, highlighting the advantages and disadvantages of each model, along with their ability to mimic the clinical manifestations of HIV-PAH.

Radial artery as a second conduit gains momentum: The RAPCO trial

In coronary artery bypass grafting (CABG), the use of an internal mammary artery (IMA) to graft the left anterior descending coronary artery (LAD) improves survival and reduces the need for repeat revascularization. The other IMA, radial artery (RA), and saphenous vein (SV) have contested to complete the surgical revascularization. For that purpose, SV remains the most commonly used conduit despite current evidence in favor of arterial grafts. To determine which conduit is best for grafting the second most important coronary artery, Buxton and colleagues have recently published the long term results of their “Radial Artery Patency and Clinical Outcomes (RAPCO)” trial.