Cardiac Tamponade Research Articles

A Novel Infusion Port for Recurrent Massive Pericardial Effusion: A Case Report

Abstract Background Patients with recurrent massive pericardial effusion are at risk of recurrent cardiac tamponade. The current standard-of-care includes repeat pericardiocentesis or pericardial window when recurrent effusions cause hemodynamic compromise. Here we report a case of a patient in whom an infusion port was used for drainage of recurrent pericardial effusion. Patient was followed up for 10 months demonstrating convenience and safety of use without evidence of cardiac tamponade. Case Summary We present a patient with recurrent massive pericardial effusion after previously undergoing two difficult pericardiocentesis of posteriorly located pericardial effusion causing tamponade. An infusion port was implanted and periodical follow-up and drainage through the port was performed. During follow-up, there was no evidence of tamponade caused by recurrence of pericardial effusion and no complications from the port. Discussion Pericardiocentesis can be challenging in certain circumstances such as loculated or posteriorly located pericardial effusion. For patients with recurrent effusion, there is incremental risk of serious complications with every pericardiocentesis. This case illustrates the feasibility of using an infusion port in recurrent pericardial effusion. After subcutaneous implantation of the infusion port, repeat pericardiocentesis and its related complications were avoided. Later pericardial decompression and intrapericardial administration of medications were simple and safe by accessing the port top.

Apixaban removal during emergency surgery for type a acute aortic dissection. a prospective cohort study

Background: Acute type A aortic dissection (ATAAD) has a high mortality, and acute aortic repair is the only curative treatment. In patients treated with factor Xa (FXa) inhibitors, the risk of severe disease-related complications such as cardiac tamponade and hemodynamic shock must be balanced against the potential for severe perioperative bleeding. The aim was to study intraoperative changes in plasma levels of the FXa inhibitor apixaban when using hemoadsorption during acute thoracic aortic repair. Materials and Methods: This is a single-center prospective cohort study. Eight apixaban-treated patients presenting with ATAAD underwent acute thoracic aortic repair with intraoperative hemoadsorption with CytoSorb®. Apixaban concentrations were measured at the start of cardiopulmonary bypass (CPB), and after 5, 15, 30, 60 and 90 minutes of CPB, at CPB weaning, 30 minutes after CPB weaning and 24 hours postoperatively, using ultraperformance liquid chromatography mass spectrometry (UPLC-MS). Results: After 30 minutes of CPB with hemoadsorption, mean apixaban concentration (± SD) was reduced by 59% from 108 (± 69) µg/L to 44 (± 20) µg/L (P = 0.009). There was a further reduction to 37 (± 17) µg/L at CPB weaning (P = 0.008). Apixaban concentration displayed an increase to 56 (± 29) µg/L 24 hours postoperatively (P = 0.01). In-hospital mortality was 25%. Mean 24H chest tube drainage volume was 621 (± 136) mL. Conclusion: Intraoperative hemoadsorption lowers apixaban levels in patients undergoing emergency surgery for ATAAD. Further research is needed to determine its impact on perioperative bleeding complications and mortality.

A case of late-onset cardiac tamponade after right lower lobectomy

A case of late-onset cardiac tamponade after right lower lobectomy

Pericardial Tamponade Two Years after Central Venous Catheter Implantation in a Patient with Breast Cancer: A Case Report

We report a rare and diagnostically challenging case of pericardial tamponade in a breast cancer patient, treated two years earlier. Echocardiogram and an enhanced computed tomography (CT) scan revealed a large mass in the right pericardium with indistinct borders. A positron emission tomography-computed tomography (PET-CT) scan showed no uptake of fluorine-18 fluorodeoxyglucose (18F-GDP) by the mass. Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement confirmed no signal enhancement within the mass and a clear border, decisively ruling out malignancy. This case highlights the importance of late gadolinium enhancement in this diagnostically challenging case and explores the pericardial tamponade development mechanism.

Endoscopic-assisted, minimally invasive versus sternotomy total arterial multivessel bypass grafting.

This single center study compared the perioperative outcomes after total arterial multivessel revascularization through endoscopic-assisted, minimally invasive surgery compared to a conventional sternotomy approach. In this retrospective, propensity score matched (PSM) cohort study, a total of 740 patients were analyzed (Endo-CAB, N = 92; Sternotomy N = 648). After PSM (1:2 ratio), 73 Endo-CAB and 137 sternotomy patients were compared with an equal number of distal anastomoses (Endo-CAB 2.3 vs Sternotomy 2.4 anastomoses per patient, p = 0.082). We used "textbook outcome" as a patient-orientated outcome measure, defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischaemia, cardiac tamponade, cerebrovascular events, wound infection, new onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (>7 days). Patients undergoing Endo-CAB had significantly more often a textbook outcome compared to the sternotomy group (78.1% vs 59.1%, p = 0.009). Endo-CAB patients had shorter hospital stay (4.0 vs 6.0 days, p < 0.001), less postoperative blood loss (360 vs 490 ml, p < 0.001) and a significant reduction of new onset postoperative atrial fibrillation (5.5% vs 17.5%, p = 0.015). Other postoperative outcomes were comparable for both groups. Total arterial Endo-CAB demonstrates excellent postoperative outcomes compared to a sternotomy approach for multivessel coronary artery disease. These findings provide a strong basis for further expanding the multivessel Endo-CAB program.

Comparison of Therapeutic Effects Between Pulsed Field Ablation and Cryoballoon Ablation in the Treatment of Atrial Fibrillation: A Systematic Review and Meta-analysis

Pulsed field ablation (PFA) is a novel nonthermal ablation technique for the treatment of atrial fibrillation (AF) patients, with safety comparable to traditional catheter ablation surgery. The present study aims to evaluate and compare the procedural efficiency and safety profiles of PFA and cryoballoon ablation (CBA) in the management of AF. We performed a systematic search across PubMed, the Cochrane Library, and Embase databases, encompassing the literature up to February 2024, to inform our systematic review and meta-analysis. When assessing outcome indicators, the risk ratio and its corresponding 95% confidence interval (CI) were calculated for dichotomous variables. For continuous variables, the mean difference (MD) and the associated 95% CI were determined. In this scenario, a relative risk (RR) value of less than 1 and an MD value of less than 0 are deemed favorable for the PFA group. This could translate to a reduced likelihood of procedural complications or enhanced procedural performance within the PFA group. In this analysis, 9 observational studies encompassing 2875 patients with AF were included. Among these, 38% (n = 1105) were treated with PFA, while 62% (n = 1770) received CBA. The results indicated that PFA was associated with a significantly shorter procedural duration compared with CBA, with an MD of −10.49 minutes (95% CI, −15.50 to −5.49; P &lt; 0.0001). Nevertheless, no statistically significant differences were observed when comparing the 2 treatment cohorts concerning fluoroscopy time (MD, 0.71; 95% CI, −0.45 to 1.86; P = 0.23) and the recurrence of atrial arrhythmias during follow-up (RR, 0.95; 95% CI, 0.78–1.14; P = 0.57). In terms of perioperative complications, the PFA group showed a significantly decreased risk of phrenic nerve palsy (RR, 0.15; 95% CI, 0.06–0.39; P &lt; 0.0001) and an increased risk of cardiac tamponade (RR, 3.48; 95% CI, 1.26–9.66; P = 0.02) compared with the CBA group. No significant differences were noted between the PFA and CBA groups regarding the incidence of stroke/transient ischemic attack (RR, 0.99; 95% CI, 0.30–3.22; P = 0.99), vascular access complication (RR, 0.87; 95% CI, 0.36–2.10; P = 0.76), atrial esophageal fistula (RR, 0.33; 95% CI, 0.01–8.13; P = 0.50), and major or minor bleeding events (RR, 0.39; 95% CI, 0.09–1.74; P = 0.22). Our research results indicate that compared with CBA, PFA not only shortens the procedure time but also demonstrates noninferiority in terms of fluoroscopy duration and the recurrence rate of atrial arrhythmias. PFA and CBA have both demonstrated their respective advantages in perioperative complications.

Characteristics and In-Hospital Outcomes of Single-Vessel Coronary Disease Intervention: A Propensity-Matched Analysis of the National Inpatient Sample Database 2016–2020

Background/Objectives: Few studies have analyzed in-hospital complications and events following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) procedures for patients who underwent these interventions for single-vessel coronary artery disease (CAD). This study aims to compare the outcomes of PCI and CABG in such patients using a large propensity-matched real-world database based on procedural codes. Methods: Adult patients receiving PCI or CABG for single-vessel CAD were identified from the 2016–2020 National Inpatient Sample (NIS) database. Any cases targeting multi-vessel disease or employing a multi-treatment approach were excluded using appropriate procedural codes. Differences in events and complications from admission to discharge were studied between the two procedures (PCI vs. CABG) via logistic regression analysis. Results: After propensity matching with 273,380 patients in both groups, complication risks such as cardiac tamponade (aOR: 3.6 [3.27–3.96]), acute kidney injury (aOR: 1.53 [1.51–1.56]), cardiogenic shock (aOR: 1.38 [1.34–1.40]), procedural bleeding (aOR: 1.75 [1.67–1.83]), acute ischemic stroke (aOR: 1.89 [1.80–1.97]), and all-cause mortality (aOR: 1.05 [1.02–1.08]) were higher among CABG patients. No differences were observed for events of cardiac perforation (aOR: 0.92, [0.84–1.01]). Conclusions: In this large real-world propensity-matched analysis, CABG was associated with higher risks of multiple in-hospital complications and all-cause mortality compared to PCI following a single-vessel coronary intervention.

Abstract 4113854: Outcomes Of Atrial Fibrillation Ablation In Elderly: A Retrospective Cohort Study

Introduction: Atrial fibrillation (Afib) is a common cardiac arrhythmia that increases in prevalence with age. Ablation has been widely used for managing Afib, but its outcomes in octogenarians have been less thoroughly investigated. Research Question: This study aims to assess the in-hospital outcomes of Afib ablation in patients aged above 80 compared to those below 80 years old. Methods: Data was obtained from the Nationwide Inpatient Sample database from January 2016 to December 2020. The study included all adult patients with a primary discharge diagnosis of Afib who underwent catheter ablation during their hospitalization. These patients were then categorized into two groups based on age: below 80 and above 80 years. In-hospital outcomes for these groups were then looked at. The primary outcome was inpatient mortality. Secondary outcomes were the length of stay, cost of hospitalization, cardiac arrest, cardiac tamponade, arrhythmias, acute respiratory failure, acute renal failure, procedural complications as well as the need for dialysis, transfusions, pressors, ventilators, and tracheostomy. Results: Out of about 35 million admissions screened, 403,247 patients had Afib as their primary discharge diagnosis, of these, 17,927 patients underwent catheter ablations during their hospitalization. Amongst them, 3,051(17%) were above the age of 80 years. The in-hospital mortality was slightly higher in the elderly compared to the younger cohort (1.1% vs 0.5%, aOR: 1.87; 95% CI: 1.20-2.92, p=0.006). They had a longer hospital stay (5.14 days vs. 3.72 days, p&lt;0.001) and lower hospitalization costs (USD 138,091 vs. USD 162,788, p&lt;0.001). Complications such as acute respiratory failure and acute renal failure were more frequent in the older age group, while no significant differences were observed in cardiac arrest, cardiac tamponade, ventricular arrhythmias, and most device-related complications. The need for new dialysis, mechanical ventilation, and pressor use was significantly less in the above-80 group. Conclusion: Afib ablation in older adults, results in slightly higher in-hospital mortality and longer hospital stays compared to younger patients. Despite these differences, the overall complication rates are comparable, suggesting that age alone should not deter the selection of patients for Afib ablation. Further studies are needed to validate these findings and optimize management strategies for the elderly population.

Abstract 4135360: Eosinophilic Myocarditis: An Atypical Presentation with a Labile Course: A Case Report

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.

Abstract 4135286: Comparative Efficacy of Intracardiac and Transesophageal Echocardiography in Left Atrial Appendage Occlusion: A Meta-Analysis of Clinical Outcomes

Background: Left atrial appendage occlusion (LAAO) is essential for stroke prevention in patients with non-valvular atrial fibrillation where anticoagulation is contraindicated. Intracardiac Echocardiography (ICE) has been proven effective and safe for LAAO since 2011, yet adoption rates remain low, with only 2.2% of LAAOs guided by ICE between 2015 and 2019. Transesophageal Echocardiography (TEE), the current gold standard, and ICE differ significantly in operational dynamics and patient impacts, influencing procedural outcomes. Objective: This study aims to compare the efficacy and safety of ICE and TEE in facilitating LAAO, offering insights into their comparative clinical use. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. Searches were performed in MEDLINE/PubMed, OVID, and Scopus through December 2023, comparing ICE and TEE in LAAO. Inclusion criteria centered on studies reporting technical success, with secondary outcomes including length of stay (LOS), mortality, and adverse outcomes such as stroke, transient ischemic attacks (TIA), pericardial effusion, cardiac tamponade, device thrombosis, device embolization, and peri-device leaks. Data synthesis employed statistical methods utilizing R Studio. Results: Fourteen studies involving 4184 patients were included. The meta-analysis revealed no significant differences in technical success (OR 1.34, 95% CI: [0.76, 2.36]), LOS (OR 1.66, 95% CI: [0.80, 3.42]), or mortality (OR = 1.00, 95% CI: [0.50, 2.00]) between ICE and TEE. Similarly, non-significant differences were noted in stroke, TIA, pericardial effusion, and device leaks, with minimal heterogeneity (I 2 = 0%). Conclusion: ICE and TEE provide comparable clinical outcomes in LAAO, with no significant efficacy or safety differences. These results suggest that the choice between ICE and TEE should be based on procedural convenience, patient anatomy, and resource availability, rather than clinical outcomes alone. The equivalence in performance between these modalities allows for flexibility in clinical practice, ensuring that patient care can be customized to individual needs without compromising safety or effectiveness.

Exploring Cardiac Variability in Hypereosinophilia: Clinical Insights and Echocardiographic Findings

Introduction: The cardiac manifestations of hypereosinophilia include mainly endomyocardial fibrosis, which is the most frequently observed form. However, eosinophilic cardiopathy can manifest itself in different ways, affecting the various layers of the heart and presenting a variety of clinical and echocardiographic presentations. Aim: The aim of our study is to describe the various aspects of cardiac involvement observed in hypereosinophilia, based on our case series and data from the literature. Methods: This is a retrospective, descriptive study of five observations illustrating the diversity of eosinophilic cardiopathy, from the cardiology department of the Mohammed VI University Hospital in Marrakech, over a period of 12 months. Results: Over the period of the study, five patients presented with cardiac damage in the context of hypereosinophilia. The mean age was 53.8 years, with a predominance of women (sex ratio 0.66). In the majority of cases, the discovery of cardiac involvement was incidental to a cardiovascular check-up requested during the course of their medical condition. All cases had high levels of hypereosinophilia, with an average of 5681. These observations illustrate the wide variety of aetiologies of hypereosinophilia, all of which were represented: 3 cases of Churg-Strauss syndrome, 1 case of idiopathic hypereosinophilia syndrome, and 1 case of DRESS syndrome. The cardiac disorders observed were hypokinetic cardiomyopathy at the dilated stage in 60% of cases, acute eosinophilic myocarditis in 20%, and acute pericarditis in the remaining cases. The outcome was marked by an improvement in the FE in 60% of cases, stabilisation in 20%, and a fatal outcome in the remainder. Treatment is based on symptomatic therapy of the CHF and treatment of the underlying aetiology. Discussion and Conclusion: Eosinophils are cytotoxic through the release of granular proteins that initially attack the endocardium, leading to thrombosis and embolic events. Subsequently, this aggression contributes to fibrosis and valvular complications. Cardiac damage can also manifest itself as potentially serious acute myocarditis or pericarditis, which can progress to cardiac tamponade. These cardiac disorders and the diversity of possible aetiologies serve as a reminder that vital prognosis may be at stake in the acute phase, and to emphasise that functional prognosis depends on early echocardiographic screening and rapid initiation of treatment to limit the risk of thrombo-embolic and fibrosing complications.

An Observational Study of Patients Presenting in Hypotension and Shock to Emergency Room by Applying RUSH Protocol

Introduction: Care of the patient with shock can be one of the most challenging issues in emergency medicine. The early use of ultrasound at the bedside in such emergency is a very valuable tool to determine the type of shock. Rapid Ultrasound in SHock (RUSH) protocol done by emergency physicians is one such protocol which is being underused. Hence, we conducted this study to assess the effectiveness of the RUSH protocol for patients presenting with undifferentiated hypotension and shock. Materials and methods: This was prospective observational study done on a total of 100 patients presented with hypotension and shock. We performed an early bedside sonographic examination for participants based on RUSH protocol and type of shock was determined. Then the definitive interventions were performed as per the type of shock. The outcome measures were determined either till the survival to discharge from the hospital or till the in-hospital death of the patient. The data was analysed using SPSS version25. Results: In this study, the type of shock most commonly found overall was hypovolemic shock (40%) followed by cardiogenic shock (27%) and distributive shock (17%). Contractility of left ventricle, size of right ventricle, inferior venacava caliber, hemoperitoneum, pneumothorax, hemothorax, pulmonary edema, pleural effusion and lungs consolidation were statistically significant in determining the type of shock except cardiac tamponade, abdominal aortic aneurysm/dissection and deep vein thombosis. Majority of the interventions performed were fluid resuscitation (41%), vasopressors and inotropes (28%) and laparotomy (9%) and were statistically significant (p=0.001). Among all patients, 73% survived and 27% died. The outcome was statistically significant (p=0.002). Conclusion: RUSH protocol used for undifferentiated hypotension and shock is an effective tool at the bedside as an early approach to diagnose the type of shock. It will also help in determining early definitive interventions in shock states and thereby having better patient outcomes.

Outcomes of Older Patients With Cardiogenic Shock Using the Impella Device - Insights From the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD).

Aging has progressed in several regions of the world with more older patients experiencing acute cardiovascular disease. Impella is a percutaneous potent circulatory support device associated with substantial cost and potential device-related complications. We analyzed the Japanese nationwide registry, encompassing consecutive patients with cardiogenic shock using Impella. Among 5,718 patients treated between 2020 and 2022, we compared older patients (≥75 years) with younger patients. The primary outcome was the Kaplan-Meier estimated 30-day mortality, and the secondary outcome was Impella-related complications. The median age of the 5,718 patients was 69 (58-77) years, and 1,807 (31.6%) were older, with smaller body mass index, frequent acute coronary syndrome, and infrequent myocarditis. Comorbidities were frequently observed in older patients with a higher ejection fraction and less frequency of extracorporeal membrane oxygenation. Older patients had a higher 30-day mortality than younger patients (38.9% vs. 32.5%; P<0.0001). The 30-day mortality was statistically equivalent among older subsets (75-79 vs. 80-84 vs. ≥85 years). Device-related complications similarly occurred similarly among the older subsets, except for a modest increase in cardiac tamponade and limb ischemia. Older age, body mass index, myocarditis, prior arrhythmia, shock severity, renal and hepatic impairment, and limb ischemia were associated with 30-day mortality. The selected older patients using Impella exhibited modestly higher 30-day mortality with similar safety profiles. A longer follow up and optimal patient selection are important.

Management of iatrogenic atrial perforation caused by pacemaker electrodes: a case report

BackgroundThe complications associated with cardiac device implants ranges between 5.3% and 14.3%. Cardiac perforation due to “leads” represent a very rare complication of cardiac device implantation, ranging between 0.3% and 0.7%. Clinically, they can manifest different, nonspecific symptoms; hence, the diagnosis may not be immediate.Case presentationOur clinical case describes the successful treatment of cardiac tamponade occurring in a Caucasian 79-year-old man following a pacemaker implantation. Two days after the procedure, the patient reported an episode of nonspecific chest pain associated with syncope. The echocardiogram performed revealed a pericardial effusion in the apical area, along the right chambers, with a thickness of 7 mm, not hemodynamically significant. A chest computed tomography scan with contrast showed hemopericardium (maximum thickness of 11 mm), caused by an atrial perforation. A few hours later, the patient experienced hemodynamic instability. For this reason, an urgent sternotomy was performed with drainage of a significant hemopericardial effusion, revealing a perforation of the upper free wall of the right atrium with pericardial injury caused by the retractable screw lead. The perforation site was sutured and the sternal wound was closed. The patient was discharged after 4 days without further complications. At the control visit, scheduled 30 days after the hospital discharge, the patient was in good conditions.ConclusionsAlthough the atrial perforations from leads are very rare complications of pacemaker implantation procedures, they are potentially lethal. In conclusion, this clinical case highlights the need, before hospital discharge, of an accurate screening for evaluation the pericardial effusion in patients that undergo to the cardiac implantable electronic devices.

Masson tumor of the right atrial appendage presenting as cardiac tamponade: a case report

BackgroundIntravascular papillary endothelial hyperplasia (Masson tumor) is a rare, benign vascular tumor characterized by the proliferation of endothelial cells within blood vessels. While it typically affects the skin and subcutaneous tissues, it can occasionally appear in unusual locations.Case presentationWe report a rare case of Masson tumor located in the right atrial appendage of a healthy individual. This case was complicated by atrial wall rupture and subsequent cardiac tamponade. The tumor was successfully resected under cardiopulmonary bypass.ConclusionThis case highlights a rare occurrence of Masson tumor in the heart, emphasizing the importance of prompt surgical intervention to prevent life-threatening complications such as cardiac tamponade.

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p &lt; 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p &gt; 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3–97.3] and 82.8% [95% CI, 68.1–97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Overcoming Challenges in Kabul, Afghanistan: Successful Management of Mid-Portion Left Anterior Descending Artery Ellis Class 3 Coronary Artery Perforation, Complicated by Cardiac Tamponade and Concurrent Cardiac Arrest

Overcoming Challenges in Kabul, Afghanistan: Successful Management of Mid-Portion Left Anterior Descending Artery Ellis Class 3 Coronary Artery Perforation, Complicated by Cardiac Tamponade and Concurrent Cardiac Arrest

P44 An acutely unwell and rare presentation of systemic lupus erythematosus; a case report

Abstract Introduction Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with multisystem involvement. The condition has varying clinical presentations from mild mucocutaneous manifestations to severe multiorgan and central nervous system involvement. It is challenging to diagnose someone with SLE during acute admission. Apart from infection and malignancies, autoimmune and connective tissue diseases should always be one of our differentials in an acutely unwell patient with multisystem involvement. This case demonstrates how unwell and rare a patient with SLE can present. We also acknowledge the need to further understand and raise awareness of this uncommon condition. Case description A 48 year old Thai lady with no known medical illness presented with 2-3 weeks history of viral like illness. On admission, she was tachycardic, hypotensive and hypoxic. Clinical examination revealed bi-basal crepitations and elevated JVP. Her ECG showed sinus tachycardia. Admission bloods showed anemia, raised white cell count, lymphopenia, thrombocytopenia, raised inflammatory markers and acute kidney injury (AKI). CT scan revealed evidence of pericardial effusion with small free fluid in abdomen and pelvis. ECHO showed large pericardial effusion and pericardiocentesis was performed which drained purulent fluid. Blood culture was positive for E. Coli. 3rd Day blood tests were strongly positive for CTD screening. She was reviewed by the rheumatology team and was diagnosed as acute presentation of SLE causing serositis having fulfilled the SLICC criteria with E. Coli bacteremia. SLE DAI – 2K score was 11. She reported history of Raynaud’s since moving to UK, hair loss and two miscarriages in the past. She denied history of oral ulcers, facial rash or significant joint involvement. Renal team advised that AKI was due to infection rather than lupus. She was commenced on high dose oral prednisolone (40 mg/day) and antibiotics. Her condition responded to steroids and subsequently was commenced on mycophenolate as outpatient. Discussion SLE is an autoimmune disease that affects multiple organ systems. Symptoms and signs can vary although majority of patients present with cutaneous manifestation. Most of the clinical manifestations of the disease are due to abnormal inflammatory response. Patients with SLE are usually diagnosed at outpatient settings although they can present acutely unwell as seen in this patient. Serositis refers to inflammation of serous tissue which includes pleura, pericardium and peritoneum. It is considerably a rare condition which is only seen in only around 10% of patients with SLE. Patients can present with shortness of breath, abdominal pain, diarrhoea, fatigue chest pain and even cardiac tamponade. Due to the heterogeneity of SLE presentations, it is challenging for clinicians to diagnose and manage the symptoms. Besides infection and malignancies, it is always important to consider connective tissue disease as one of the differentials in an acutely unwell patient presenting with multisystem involvement. SLICC criteria can be used as a diagnosing tool for SLE which includes clinical and immunological criteria. SLEDAI-2K score can be used to assess disease activity. Her biochemical parameters as well as clinical symptoms drastically improved following steroid initiation. Early recognition and treatment initiation can improve mortality and morbidity significantly. Despite how unwell she was during admission; she improved quickly and was discharged relatively early. Her condition continues to improve on DMARDs, and she is on regular clinic follow up. Key learning points • A good clinical history and examination is essential and aids reaching a diagnosis. As reflected in this case, our patient was a female at childbearing age, south Asian (non-Caucasian ethnicity) who presented with multisystem involvement. Her initial finding of serositis, acute kidney injury, anemia, raised ESR and E. coli bacteremia were not fitting with a typical sepsis picture. There should be strong grounds for considering SLE during such clinical presentations. Suspecting SLE in an acute setting is really challenging due to various reasons, like wide symptomology of SLE, minimal exposure of SLE to physicians and their tendency of leaning towards other common conditions, like sepsis. As SLE is mostly diagnosed as outpatient, inpatient presentations are rare. Furthermore, blood results for connective tissue disease which is a major criteria for diagnosis, can take between 3 to 5 working days to be reported. However, early and appropriate consideration of autoimmune conditions as differentials of an acutely ill patient with multisystem involvement can expedite the process of diagnosis, involvement of related specialty and commencement of appropriate treatment. This approach will benefit patients producing favourable outcomes and minimal hospital stay.

Atypical Presentation of Lung Adenocarcinoma as cardiac tamponade and venous thromboembolism: A Case Report

Atypical Presentation of Lung Adenocarcinoma as cardiac tamponade and venous thromboembolism: A Case Report

In-hospital outcomes of cardiac tamponade in patients with pulmonary hypertension: A contemporary analysis.

Cardiac tamponade (CT) has an atypical presentation in patients with underlying pulmonary hypertension (PH). Evidence regarding the impact of PH on CT in-hospital outcomes is lacking. We used the National Inpatient Sample database to identify adult hospitalizations with a diagnosis of CT between 2016 and 2020, using relevant ICD-10 diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with and without a PH. Multivariate logistic regression analyses and case-control matching were performed, adjusting for age, race, gender, and statistically significant co-morbidities between cohorts. A total of 110,285 inpatients with CT were included, of which 8,670 had PH. Patients with PH tended to be older (66 ± 15.7) and female (52.5%), had significantly higher rates of hypertension (74% vs 65%), CAD (36.9% vs. 29.6%), CKD (39% vs 23%), DM (32.1%, vs. 26.9%), chronic heart failure (19.0% vs 9.7%) and COPD (26% vs 18%)(P<0.001 for all). After multivariate logistic regression, PH was associated with higher all-cause mortality (aOR 1.29; 95% CI: 1.11-1.49), higher rates of cardiogenic shock (aOR: 1.19; 95% CI: 1.01-1.41), ventricular arrythmias (aOR: 1.63; 95% CI: 1.33-2.01), longer length of stay (11 days vs 15 days), and higher total hospitalization costs ($228,314 vs $327,429) in patients presenting with CT. Despite pericardiocentesis being associated with lower in-hospital mortality, patients with PH were less likely to undergo pericardiocentesis (aOR: 0.77; 95% CI: 0.69-0.86). PH was associated to increased in-hospital mortality and a higher rate of cardiovascular complications in an inpatient population with CT. Pericardiocentesis was associated with reduced mortality in patients with CT, regardless of whether they had PH. However, patients with PH underwent pericardiocentesis less frequently than those without PH.