Moderate Pericardial Effusion Research Articles

C33. Complex ebstein anomaly in adult patient: a case report

Abstract Background Ebstein’s anomaly is a rare form of congenital heart disease. In adult often present with arrhythmias, progressive cyanosis, and right heart failure. Management is complex and individualized. Case Summary A 24-year-old woman presented to the emergency room with heart failure presentation, palpitations and fainting. ECG examination shows abberant SVT with pulse, hemodinamically was stable with peripheral saturation 94% without oxygen supplementation. The patient then carried out cardioversion and got anti-arrhythmia amiodarone. Resting ECG obtained sinus rhythm right axis deviation with incomplete LBBB (splintered QRS). Echocardiography examination revealed displacement of the tricuspid valve, a large atrialized component of the right ventricle, the anterior leaflet of the tricuspid valve moves freely with bidirectional shunt ASD and moderate pericardial effusion, confirmed for Ebstein's anomaly type B . Diuresis therapy was given and anti-arrhythmic therapy was continued. Echocardiographic evaluation showed reduced pericardial effusion to a minimum. Patients were scheduled for electrophysiological studies and angiographic evaluation and total corrections were planned. Discussion Ebstein anomaly is a characterized by abnormally formed and apically displaced leaflets of Tricuspid caused by is failure of proper delamination of the tricuspid valve, primarily of the septal and anterior leaflets from ventricular myocardium. The cardinal symptoms in Ebstein’s anomaly are cyanosis, right-sided heart failure, arrhythmias, and sudden cardiac death. Surgery is indicated in adults with symptoms of heart failure. Medical therapy is generally used only for temporary stabilization : diuretic therapy for volume overload, control of heart rhythm abnormalities, and standard medical therapy for left ventricular systolic dysfunction.

C21. Cardiac Complications in Immunocompromised Patient : A Case Report

Abstract Background Cardiovascular diseases in human immunodeficiency virus (HIV)-positive patients are becoming increasingly detected in developing countries. Pericardial involvement may be manifested as acute pericarditis, constrictive pericarditis, symptomatic pericardial effusion and cardiac tamponade. The aim of this report is to present a patient with AIDS clinical stage IV who developed pericarditis and pericardial effusion. Case Summary A 27-year-old male came to our ER with 7-day fever and delirium syndrome. He has been diagnosed with AIDS clinical stage IV for the past 3 years with the latest CD4 count was 6/mm3. Serial Transthoracic Echocardiography (TTE) revealed small to moderate circumferential pericardial effusion, thickening of pericardium and reduced left ventricular ejection fraction without signs of cardiac tamponade from TTE. Upon hospitalization, he developed signs of hypotension without distended jugular veins nor muffled heart sounds. It was decided to initiate supportive treatment and NSAIDs without pericardiocentesis. The patient recovered uneventfully. As an outpatient, no other cardiovascular complications developed. Discussion Pericardial conditions are the most frequent cause of heart disease in patient with HIV infection. Most cases are mild and asymptomatic. Pericardial effusion may be marker of end-stage HIV infection because it is associated with low CD4 cell count and is often caused by opportunistic infections and malignant neoplasms. Treatment of pericarditis in HIV patients is no different from that in general population. Asymptomatic patients with small pericardial effusion without tamponade require no intervention.

C21. Cardiac Complications in Immunocompromised Patient : A Case Report

Abstract Background Cardiovascular diseases in human immunodeficiency virus (HIV)-positive patients are becoming increasingly detected in developing countries. Pericardial involvement may be manifested as acute pericarditis, constrictive pericarditis, symptomatic pericardial effusion and cardiac tamponade. The aim of this report is to present a patient with AIDS clinical stage IV who developed pericarditis and pericardial effusion. Case Summary A 27-year-old male came to our ER with 7-day fever and delirium syndrome. He has been diagnosed with AIDS clinical stage IV for the past 3 years with the latest CD4 count was 6/mm3. Serial Transthoracic Echocardiography (TTE) revealed small to moderate circumferential pericardial effusion, thickening of pericardium and reduced left ventricular ejection fraction without signs of cardiac tamponade from TTE. Upon hospitalization, he developed signs of hypotension without distended jugular veins nor muffled heart sounds. It was decided to initiate supportive treatment and NSAIDs without pericardiocentesis. The patient recovered uneventfully. As an outpatient, no other cardiovascular complications developed. Discussion Pericardial conditions are the most frequent cause of heart disease in patient with HIV infection. Most cases are mild and asymptomatic. Pericardial effusion may be marker of end-stage HIV infection because it is associated with low CD4 cell count and is often caused by opportunistic infections and malignant neoplasms. Treatment of pericarditis in HIV patients is no different from that in general population. Asymptomatic patients with small pericardial effusion without tamponade require no intervention.

C51. Impending Rupture in Acute Type A Aortic Dissection : Case Report

Abstract Background Acute aortic dissection is a life threatening condition that remains a challenge to diagnose and treat. 67% patients was presented with Acute type A aortic dissection (ATAAD) and often accompanied with some complications. Case Summary A 40-year-old male with risk factor hypertension was presented with sudden sharp tearing-like chest pain and radiating to the back 3 hours before admission. He had transient decrease of consciousness and waken up spontaneously. He was compos mentis, with normal JVP, normal heart sound, no pulsus deficit, hypotension, cold acral and oliguria. He got fluid rehydration and the BP was stabilized. Haemoglobin was normal with increase D-Dimer. The ECG was normal and chest radiography revealed cardiomegaly and widening mediastinum. From eyeballing echocardiogram showed moderate pericardial effusion without right atrial and right ventricle collapse. A CT scan angiography was performed and revealed an Aortic Dissection Stanford A Debakey I. Discussion The development of an evidence-based strategy to rule out aortic dissection in patients presenting chest pain would be useful to diagnose patients with chest pain. Rapid diagnosis of dissection is most likely when CT is a part of the diagnostic testing. Hypotension and shock occurred in > 25% of patients with type ATAAD and in this patient was associated transient loss of consciousness. This patient was in impending rupture condition. The definitive treatment for this patient was emergency aortic repair surgery. We was succeded to stabilize the patient then referred to a cardiothoracic surgeon in 24 hours later.

C51. Impending Rupture in Acute Type A Aortic Dissection : Case Report

Abstract Background Acute aortic dissection is a life threatening condition that remains a challenge to diagnose and treat. 67% patients was presented with Acute type A aortic dissection (ATAAD) and often accompanied with some complications. Case Summary A 40-year-old male with risk factor hypertension was presented with sudden sharp tearing-like chest pain and radiating to the back 3 hours before admission. He had transient decrease of consciousness and waken up spontaneously. He was compos mentis, with normal JVP, normal heart sound, no pulsus deficit, hypotension, cold acral and oliguria. He got fluid rehydration and the BP was stabilized. Haemoglobin was normal with increase D-Dimer. The ECG was normal and chest radiography revealed cardiomegaly and widening mediastinum. From eyeballing echocardiogram showed moderate pericardial effusion without right atrial and right ventricle collapse. A CT scan angiography was performed and revealed an Aortic Dissection Stanford A Debakey I. Discussion The development of an evidence-based strategy to rule out aortic dissection in patients presenting chest pain would be useful to diagnose patients with chest pain. Rapid diagnosis of dissection is most likely when CT is a part of the diagnostic testing. Hypotension and shock occurred in > 25% of patients with type ATAAD and in this patient was associated transient loss of consciousness. This patient was in impending rupture condition. The definitive treatment for this patient was emergency aortic repair surgery. We was succeded to stabilize the patient then referred to a cardiothoracic surgeon in 24 hours later.

Abstract 17228: Not Just Another Knick In The Wall: An Unusual Case Of Multiple Arterial Aneurysms

Case Presentation: 47-year-old Liberian woman with a history of latent TB and no prior cardiac history presented with dyspnea, palpitations, and weight loss. She had fevers, tachycardia, and cervical lymphadenopathy. Cardiac exam showed widened pulse pressure, systolic and diastolic murmur, and features of heart failure. TTE showed dilated left ventricle with preserved ejection fraction, aortic root aneurysm compressing left atrium, severe aortic and mitral regurgitation, and moderate pericardial effusion with no tamponade. CT angiogram of neck, chest and abdomen showed right subclavian artery mycotic aneurysm, large left supraclavicular lymphadenopathy, multiple aortic arch, and descending thoracic aorta mycotic aneurysms. She underwent emergent surgical intervention. Intraoperative TEE revealed rupture of aortic root aneurysm into left ventricular outflow tract causing a fistula, perforated anterior mitral leaflet, and distortion of the left atrial wall. She underwent mitral and aortic tissue valve replacement, aortic root replacement, and a pericardial patch repair of the left atrial wall. Subsequently, she underwent right subclavian artery aneurysm resection, right carotid axillary bypass, and vertebral artery reimplantation. Aortic valve pathology was suggestive of endocarditis with negative cultures. Lymph node biopsy revealed non-necrotizing granulomatous inflammation with no evidence of acid-fast bacilli, fungi, and malignancy. Autoimmune workup was negative. A PET CT showed post-surgical inflammatory changes with no evidence of malignancy. Discussion: We describe an unusual case of multiple large arterial aneurysms causing severe valvular insufficiency requiring emergent surgical intervention. The patient underwent extensive workup which was unrevealing. She was treated for subacute bacterial endocarditis and suspected Bechet’s disease. Thus, the quest for a definitive diagnosis continues to elude us.

Abstract 13690: Complex Clinical Course of Unsuccessfully Revascularized Right Coronary Artery

Objective: Since onset of reperfusion era, ventricular aneurysms have become a rare complication of acute myocardial infarction, with incidence of LV inferior wall aneurysm around 5%. Guidelines recommend an ICD placement for sustained V tach after 48 hours of MI, however management of persistent V tach associated with ventricular aneurysm is uncertain. Case: The patient is a 60 year old male who presents with persistent palpitations, occurring after a mechanical fall. EKG demonstrated slow persistent V tach with HR of 121.Two and a half months prior, the patient suffered from inferior wall STEMI, unsuccessfully reperfused at another institution, secondary to iatrogenically dissected RCA. He presented at our institution 3 weeks after complaining of chest pain and diagnosed with moderate pericardial effusion, as well as large LV inferior wall aneurysm. Pericardial fluid was not large enough to drain. He represented two weeks later, with worsening SOB and tamponade physiology by TTE. A total of 2.5 L of pericardial fluid was drained over several days. CT surgery was consulted, coronary angiography was performed and demonstrated multivessel coronary artery disease. Plan was to follow up as an outpatient for surgery. Medical Decision Making: During his most recent presentation with V tach, the patient did not respond to Amiodarone infusion but underwent successful synchronized cardioversion with 30 J.He underwent CABGX2 and inferior LV endoaneurysmorrhaphy with 4x6 cm bovine pericardial patch. An ICD was implanted before his discharge. Conclusion: This patient’s V tach was likely secondary to LV aneurysm. Per our hypothesis, he would still be prone to develop V tach around the suture lines.Therefore the patient underwent an ICD implantation.

Abstract 16803: Cabozantinib Induced Cardiomyopathy; Second Reported Case Of A Rare Adverse Effect

Case Presentation: A 27-year-old female with no prior medical history was diagnosed with metastatic paraganglioma in 2016. She was started on Cyclophosphamide, Vincristine and Dacarbazine and eventually transitioned to Pembrolizumab for 2 years. Due to progression of disease, she was started on compassionate 40 mg daily Cabozantinib in 2019. Echocardiogram at that time revealed normal ventricular function. One month later, she presented with new onset hypoxic respiratory failure. ProBNP was elevated to 7854 pg/nl. TTE showed moderate pericardial effusion with cardiac tamponade physiology and LVEF of 30%. Cabozantinib was discontinued due to elevated LFT. Repeat TTE after 1 month showed recovery of LVEF to 55% and only trace pericardial effusion. Due to her aggressive malignancy Cabozantinib was reinitiated at 20mg daily. Her LVEF remained stable on multiple serial TTE for 1 year so an attempt at Cabozantinib 40 mg was made once again. One month later, she had worsening dyspnea and TTE showed LVEF drop to 35%. Cardiac MRI revealed LVEF 37% with a moderate pericardial effusion along with gadolinium uptake consistent with perimyocarditis. Cabozanitib was discontinued and Colchicine 0.6 mg daily started. Eventually, LVEF normalized and pericardial effusion resolved. Patient was restarted on Cabozanitib 20mg and has remained stable from a cardiovascular standpoint Discussion: In the past decade the rise of tyrosine kinase inhibitors, like Cabozantinib, have transformed the scope of medical oncology. In 2019 Al hussein et al described the first case of Cabozantinib induced cardiomyopathy. We present, to our knowledge, the second reported case. This case identifies a strong temporal relationship between Cabozantinib, LV systolic dysfunction and perimyocarditis with higher doses. Interestingly, our patient received Pembrolizumab for 2 years, but had heart failure symptoms only 1 month after Cabozanitib initiation. Although theoretically possible, it is unlikely Pembrolizumab was the cause, given normal TTE 2 years after initiation and strong temporal relationship to Cabozantinib. Further studies are required to establish the cardiotoxic side effects of Cabozantinib and inform guidance on cardiac monitoring.

P081 Unravelling SLE in a young male child

Abstract Background Juvenile-onset systemic lupus erythematosus (jSLE)) is a rare but severe multisystem autoimmune, inflammatory disease that can affect any organ system and cause significant morbidity and mortality. The disease onset occurs before the age of 18, however the peak age of onset is between 12 and 14 years and it affects ∼15–20% of all SLE patients. Patients with disease onset before 5 years of age are very uncommon and may be referred to as early-onset SLE. They commonly present with fever and general malaise, rash and arthritis. In addition, cases of jSLE, tend to have more severe organ manifestations and greater damage at the time of diagnosis as well as a higher incidence of renal, cardiovascular and neuropsychiatric involvement. Compared with adult-onset SLE, it is more aggressive, with higher medication burden including corticosteroids and other immunosuppressive drugs. Method and results This case report reviews the journey of a 5-year-old boy, who developed recurrent skin rashes, fever and generalised lymphadenopathy in his second year of life. After multiple hospital admissions and various investigations at different facilities spanning a year, he was admitted to the paediatric emergency unit at a tertiary hospital on account of an acute infection. On presentation, he was pyrexial. There were hypo- and hyperpigmented lesions extending over his scalp, face and upper arms as well as vasculitic lesions in his palms and soles; lip ulcers, sparse brown hair and multiple, non-tender lymph nodes in the cervical, supraclavicular and axillary regions. Respiratory examination revealed a right lobar pneumonia. Heart rate was 112 bpm and heart sounds were normal, however an echocardiogram showed a moderate pericardial effusion with no signs of tamponade. His abdomen was distended with a non-tender hepatomegaly. There was no synovitis. He was lethargic, but had no focal neurological signs. Laboratory results were as follows: normocytic anaemia (8.5 g/dl); ESR (120 mm/h); deranged transaminases; albumin (32 g/dl); Creatinine (12umol/l); urinalysis was normal, positive antinuclear antibody (1:320); positive double-stranded DNA (1:40); positive anti-smith, anti-Ro and anti-RNP antibodies; low C3, C4. A lymph node biopsy showed reactive changes only, with no evidence of haematological malignancy. The diagnosis of jSLE was confirmed at age 3yrs. The acute illness due to pneumonia was treated with antibiotics. Prednisolone 10 mg, Hydroxychloroquine (HCQ) 80 mg daily, Azathioprine 25 mg daily, calcium supplementation and gastric protection were added to manage the jSLE. He made an initial recovery and was managed in the outpatient clinic for months. However, his illness flared up again around age 4 years when he developed generalized seizures, facial and pedal oedema, low urine output, proteinuria 3+, low albumin (25 g/dl), creatinine (252umol/l) and high urine albumin-creatinine ratio (278.62 mg/mmol) reflecting new renal and CNS involvement. A renal biopsy was not available. He received pulse iv methylprednisolone 250 mg daily for 3 days followed by monthly iv cyclophosphamide therapy 500 mg (NIH Regime) which was discontinued after the 5th cycle due to haemorrhagic cystitis. He eventually continued treatment with mycophenolate mofetil 125 mg daily, HCQ 80 mg daily, Prednisolone 10 mg daily, Nifedipine and Enalapril and a year later, has low activity from the cutaneous, renal and CNS manifestations. There is renal damage (creatinine 180 μmol/l) and hypertension, as well as treatment complications from prednisolone causing bilateral cataracts. Conclusion Early diagnosis of jSLE is still a challenge and a high index of suspicion is required especially in the very young. Severe presentation and aggressive clinical course is associated with tissue damage, as in the case presented. Management is complex and we were challenged by the choice and availability of treatment suitable for the severity of his disease, bearing in mind that damage can occur early especially in a male child. In addition, it is important to consider his young age and long-term exposure to drug toxicity and complications.

Pericardial effusion as a complication of myocardial infarction : how and what to do?

Pericardial effusion after myocardial infarction is a relatively common, however the management and prognosis is not always straightforward. Regardless of effusion size, data suggests that pericardial effusion which occurs early post myocardial infarction were correlated with higher morbidity and mortality. This report describes a case of pericardial effusion occurrence after myocardial infarction and reviews published literature about the etiology and management of this complication. A 59 years old man with typical chest pain since 26 hours before refered to emergency room, sign and symptoms of cardiogenic shock, elevated cardiac marker, and electrocardiogram showing ST elevation in V1-V6, I, aVL (extensive anterior). He was observed and conservatively treated in intensive cardiology care unit. After 9 days of care, moderate pericardial effusion is revealed by echocardiography examination, which did not exist at the admission. Pericardial effusion (PE) as the complication of myocardial infarction is associated with anterior ST-segment elevation myocardial infarction (STEMI) and when there is heart failure. Poor ST-segment resolution is clearly associated with presence of PE and especially with tamponade or electromechanical dissociation. The most frequent cause of moderate PE in STEMI patients is bleeding from the infarcted wall. STEMI patients with a moderate PE have increased mortality than those with small PE or without PE, and death was attributable to free wall rupture (FWR). It is necessary to detect PE earlier with echocardiography and some deserve close monitoring to detect FWR.

Pericardial disease in patients treated with immune checkpoint inhibitors

Abstract Background There are limited data on the occurrence, associations and outcomes of pericardial effusions and pericarditis after treatment with immune checkpoint inhibitors (ICIs). Purpose To evaluate incidence of pericardial disease in patients treated with an ICI. Methods This was a retrospective study at a single academic center that compared 2842 consecutive patients who received ICIs with 2699 age- and cancer-type matched patients with metastatic disease who did not receive ICI (design 1). A pericardial event was defined as a composite outcome of pericarditis and new or worsening moderate or large pericardial effusion. The endpoints were obtained through chart review and were blindly adjudicated. To identify risk factors associated with a pericardial event, in a second analysis, we also compared patients who developed an event on an ICI to patients treated with an ICI who did not develop a pericardial event (design 2). Cox proportional hazard model and logistical regression analysis were performed to study the association between ICI use and pericardial disease as well as pericardial disease and mortality. An additional 6-week landmark analysis was performed to account for lead-time bias. Results There were 42 pericardial events in the patients treated with ICI (n=2842) over 193 days (interquartile range 64 to 411) with an incidence rate of 1.57 events per 100 person-years. There was a 4-fold increase in the risk for pericarditis or a pericardial effusion among patients on an ICI compared to controls not treated with ICI after adjusting for potential confounders (hazard ratio [HR] 4.37, 95% confidence interval [CI] 2.09–9.14, p<0.001). Patients who developed pericardial disease while on an ICI had a trend for increased all-cause mortality (HR 1.53, 95% CI 0.99–2.36, p=0.05) compared to those who did not develop pericardial disease. When comparing those who developed pericardial disease after ICI treatment to those who did not, a higher dose of corticosteroid pre-ICI (>0.7 mg/kg prednisone) was associated with increased risk of pericardial disease (HR 2.56, 95% CI 1.00–6.57, p=0.049). Conclusions ICI use was associated with an increased risk for development of pericardial disease among cancer patients and a pericardial event on an ICI was associated with a trend towards increased mortality. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health/National Heart, Lung, and Blood Institute; a gift from A. Curt Greer and Pamela Kohlberg

Prevalence and prognosis of pericardial effusion in patients affected by pectus excavatum: A case-control study

BackgroundThe presence of pectus excavatum(PEX) has been occasionally associated with pericardial effusion. Aim of the present study was to compare incidence and prognosis of pericardial effusion in a group of unselected patients with PEX vs a control group. MethodsFrom a prospective registry of consecutive patients who underwent chest CT for cardiovascular disease, subjects with a radiological diagnosis of PEX were retrospectively identified (cases); from the same registry patients (controls) without rib cage abnormalities were randomly selected, until a 1:2 ratio was reached. The presence of pericardial effusion at CT was quantified. Follow-up was obtained for a composite end-point: cardiac tamponade, need for pericardiocentesis, need for cardiac surgery for relapsing pericardial effusion. ResultsA total of 43 patients with PEX (20 females) and a control group of 86 cases (31 females) without rib cage abnormalities were identified. Pericardial effusion evaluated at CT was significatively more prevalent in patients with PEX vs control group, 37.2% vs 13.9% (p < 0.001), respectively; four patients with PEX (9.3%) had at least moderate pericardial effusion vs no subjects among the controls (p = 0.004). PEX diagnosis was significantly associated to pericardial effusion at multi-variate analysis (OR95%CI 10.91[3.47–34.29], p < 0.001). At a mean follow-up of 6.5 ± 3.4 years no pericardial events were recorded. ConclusionOur findings support the higher prevalence of pericardial effusion in patients with PEX when compared to a control group. The absence of adverse pericardial events at follow-up suggest the good prognosis of these effusions, that in the appropriate clinical setting might not be considered “idiopathic”.

SEVERE PRECAPILLARY PULMONARY HYPERTENSION ASSOCIATED WITH COMMON VARIABLE IMMUNODEFICIENCY: RESPONSE TO TREATMENT AND LONG-TERM FOLLOW UP

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary involvement in setting of common variable immunodeficiency (CVID) usually manifests as an airway disease and/or ILD. Development of severe pre-capillary PH is unusual. Herein, we present a case of severe PH associated with CVID ILD that was managed with combination therapy including inhaled treprostinil and was followed for 8 years. CASE PRESENTATION: A 34-year-old female with a diagnosis of CVID, on immunoglobulin therapy since the age of 10 years, and bronchiectasis presented in 2013 with worsening dyspnea, hypoxia, and lower extremities edema. Pro-BNP was elevated at 11,000 pg/mL and cardiac echocardiogram showed EF of 56%, severe RV dilation with severe hypokinesis, RVSP >120mm Hg, and moderate pericardial effusion. Chest CT with contrast showed bilateral areas of fibrosis with traction bronchiectasis without evidence of acute or chronic pulmonary emboli. After diuresis, RHC showed mRAP 4 mmHg, mPAP 54mmHg, PAWP 12 mmHg, CO 4.22L/min and PVR 9.95 WU. PFTs showed severe restriction, air trapping, and Dlco of 13%. The patients was referred for lung transplant evaluation but she was hesitant about transplantation. She was started on tadalafil 40 mg po daily and inhaled treprostinil that was titrated to 10 breaths QID. The patient noted subjective improvement in her dyspnea and at 1 year follow up the 6MWD improved from 303m to 465m with normalization of BNP to 27pg/ml and resolution of the pericardial effusion. Repeat RHC showed mRAP 1 mmHg, mPAP 32 mmHg, PAWP 5mmHg, CO 4.51 L/min, and PVR 5.9 WU. Over the last 8 years the patients continued vasodilator therapy with dose escalation of inhaled treprostinil (current dose of 16 breaths QID). Her last cardiac echo in 2021 showed normal RV size and function (TAPSE 28mm, and FAC 36%) and no pericardial effusion and the last RHC showed PVR 4.6 WU. The patient continues to be followed closely by transplant, ILD, and PH teams. DISCUSSION: Severe pre-capillary PH associated with CVID is not well described. We reported before, a patient with CVID without ILD who presented with severe PAH that required parenteral therapy which resulted in RV reverse remodeling and near normalization of hemodynamics. The case we are presenting here had severe pre-capillary PH associated with CVID but in setting of significant ILD with good response to pulmonary artery vasodilators including high dose inhaled treprostinil. Recently, the INCREASE trial provided the needed evidence to treat PH-ILD with inhaled treprostinil with doses up to 12 breaths QID. Here we present the unusual association between CVID and severe pre-capillary PH, describe the hemodynamic response to combination therapy that included high dose inhaled treprostinil in setting of ILD, and provide 8 years of follow up for this unusual case. CONCLUSIONS: CVID can be associated with severe pre-capillary PH. This association needs to be better characterized in the literature. REFERENCE #1: C. Salmon, K. El-Kersh, R. Kim, M. Taylor. Severe PAH Associated with CVID: Rapid Normalization with Upfront Triple Combination Therapy. American Journal of Respiratory and Critical Care Medicine 2020;201:A3755 DISCLOSURES: Speaker/Speaker's Bureau relationship with United therapeutics Please note: $5001 - $20000 by Karim El-Kersh, source=Web Response, value=Honoraria Removed 04/21/2021 by Karim El-Kersh, source=Web Response Advisory Committee Member relationship with United therapeutics Please note: $1001 - $5000 by Karim El-Kersh, source=Web Response, value=Consulting fee Removed 04/21/2021 by Karim El-Kersh, source=Web Response Advisory Committee Member relationship with Actelion Please note: $5001 - $20000 by Karim El-Kersh, source=Web Response, value=Consulting fee Removed 04/21/2021 by Karim El-Kersh, source=Web Response Advisory Committee Member relationship with United Therapeutics Please note: Current Added 04/23/2021 by Karim El-Kersh, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Actelion Please note: 2019 and 2020 Added 04/23/2021 by Karim El-Kersh, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: Current Added 04/29/2021 by Karim El-Kersh, source=Web Response, value=Honoraria Advisory Committee Member relationship with United Therapeutics Please note: Current Added 04/29/2021 by Karim El-Kersh, source=Web Response, value=Honoraria Advisory Committee Member relationship with Actelion Please note: 2019 and 2020 Added 04/29/2021 by Karim El-Kersh, source=Web Response, value=Honoraria Consultant relationship with Acceleron Pharma Please note: Current Added 04/29/2021 by Karim El-Kersh, source=Web Response, value=Consulting fee No relevant relationships by Cristina Salmon, source=Web Response No relevant relationships by Nadine Sbaih, source=Web Response

Cardiac involvement in hospitalized patients with COVID-19 and its incremental value in outcomes prediction

Recent reports linked acute COVID-19 infection in hospitalized patients to cardiac abnormalities. Studies have not evaluated presence of abnormal cardiac structure and function before scanning in setting of COVD-19 infection. We sought to examine cardiac abnormalities in consecutive group of patients with acute COVID-19 infection according to the presence or absence of cardiac disease based on review of health records and cardiovascular imaging studies. We looked at independent contribution of imaging findings to clinical outcomes. After excluding patients with previous left ventricular (LV) systolic dysfunction (global and/or segmental), 724 patients were included. Machine learning identified predictors of in-hospital mortality and in-hospital mortality + ECMO. In patients without previous cardiovascular disease, LV EF < 50% occurred in 3.4%, abnormal LV global longitudinal strain (< 16%) in 24%, and diastolic dysfunction in 20%. Right ventricular systolic dysfunction (RV free wall strain < 20%) was noted in 18%. Moderate and large pericardial effusion were uncommon with an incidence of 0.4% for each category. Forty patients received ECMO support, and 79 died (10.9%). A stepwise increase in AUC was observed with addition of vital signs and laboratory measurements to baseline clinical characteristics, and a further significant increase (AUC 0.91) was observed when echocardiographic measurements were added. The performance of an optimized prediction model was similar to the model including baseline characteristics + vital signs and laboratory results + echocardiographic measurements.

Predictors and clinical significance of pericardial effusions after pediatric heart transplantation.

We aimed to describe the incidence, risk factors, and clinical outcomes of pericardial effusions within 6months after pediatric heart transplantation (HT). A single-center retrospective cohort study was performed on all pediatric HT recipients from 2004 to 2018. Logistic regression was used to identify factors associated with pericardial effusions post-HT, and survival was compared using log-rank test. During the study period, 97 HTs were performed in 93 patients. Fifty patients (52%) had a ≥small pericardial effusion within 6months, 16 of which were, or became, ≥moderate in size. Pericardial drain was placed in 8 patients. In univariate analysis, larger recipient body surface area (p=.01) and non-congenital heart disease (p=.002) were associated with pericardial effusion development. Donor/recipient size ratios, post-HT hemodynamics, and rejection did not correlate with pericardial effusion development. In multivariable analysis, non-congenital heart disease (adjusted odds ratio 3.3, p=.01) remained independently associated with development of pericardial effusion. There were no significant differences in post-HT survival between patients with and without ≥small (p=.68) or ≥moderate pericardial effusions (p=.40). Pericardial effusions are common after pediatric HT. Patients with cardiomyopathy, or non-congenital heart disease, were at higher risk for post-HT pericardial effusions. Pericardial effusions increased morbidity but had no effect on mortality in our cohort. The risk factors identified may be used for anticipatory guidance in pediatric HT.

Pericardial effusion caused by accidently placing a Micra transcatheter pacing system into the coronary sinus

BackgroundLeadless pacemaker has been acknowledged as a promising pacing strategy to prevent pocket and lead-related complications. Although rare, cardiac perforation remains a major safety concern for implantation of Micra transcatheter pacing system (TPS).Case presentationA 83-year-old female with low body mass index (18.9 kg m−2) on dual anti-platelet therapy, was indicated for Micra TPS implantation due to sinus arrest and paroxysmal atrial flutter. The patient developed mild pericardial effusion during the procedure since the delivery catheter was accidentally placed into the coronary sinus for several times. Cardiac perforation with moderate pericardial effusion and pericardial tamponade was detected 2 h post-procedure. The patient was treated with immediately pericardiocentesis and recovered without further invasive therapy.ConclusionPericardial effusion caused by accidently placing a delivery catheter into the coronary sinus is rare but should be carefully considered in Micra TPS implantation, especially for those with periprocedural anti-platelet therapy.

Profile and early outcomes of surgical reconstruction of coronary artery atresia in children.

Coronary artery atresia is a rare coronary artery anomaly in children and has a high rate of misdiagnosis. We aimed to summarize the profile and early outcomes after the surgical reconstruction of coronary artery atresia in children. A retrospective analysis was performed in 12 consecutive patients with coronary artery atresia who were admitted to the Department of Paediatric Cardiac Surgery of Fuwai Hospital between October 2016 and September 2020. Ten patients underwent surgical reconstruction of the coronary artery with the pulmonary artery anterior wall, and 8 patients underwent concomitant mitral valvuloplasty. There were 6 females and 6 males, with an age of 1.75 years [interquartile range (IQR), 1.0-3.5] and weight of 10.0 kg (IQR, 8.9-14.75). There were 10 cases of left coronary artery atresia and 2 cases of right coronary artery atresia. All the patients were initially misdiagnosed in the outpatient clinic, but further nonselective coronary angiography confirmed the diagnosis of coronary artery atresia. In all 10 patients with mitral regurgitation, echocardiogram of the mitral valve chordae and papillary muscle revealed ischaemic changes. The clamp time was 89.0 min (IQR, 75.0-101.0), the pump time was 126.0 min (IQR, 119.0-132.0) and the intensive care unit stay time was 1.5 days (IQR, 1.0-3.0). No perioperative deaths were noted. After 9.5 months (IQR, 5.5-13.5) of follow-up, 2 patients with fractional shortening that significantly decreased to 14.1% and 14.8% died and 1 patient had moderate pericardial effusion that improved after treatment with oral diuretics. Coronary artery ultrasound and enhanced computed tomography showed a patent main coronary artery in all the patients. Coronary artery atresia in children is often associated with mitral regurgitation, and mitral valve chordae and papillary muscle exhibit ischaemic changes. Coronary artery reconstruction is safe and effective in children with coronary artery atresia.

Clinical Images: Takayasu arteritis presenting with isolated pulmonary artery involvement and pericarditis treated with bypass and tocilizumab

The patient, a previously healthy 23-year-old woman, presented with midsternal chest pain and dyspnea worsening over 2 weeks, with 6 months of fatigue, night sweats, and arthralgias. Physical examination found sinus tachycardia and a 4/6 left upper sternal border systolic murmur. The erythrocyte sedimentation rate was 91 mm/hour; the C-reactive protein level was 127 mg/L. Other bloodwork results and extensive serologic analysis were unremarkable. A transthoracic echocardiogram showed moderate pericardial effusion and concern for pulmonary hypertension. A pericardiocentesis resulted in transient symptomatic improvement. Right heart catheterization found bilateral pulmonary artery (PA) stenosis but normal PA pressures (20/15 mm Hg). Positron emission tomography-computed tomography (PET-CT) showed focal increased uptake of 18F-fluorodeoxyglucose in the main PA to the carina, with a standard uptake value (SUV) of 11.6 (A). An endobronchial ultrasound was attempted with inadequate sampling. Surgical exploration found a hard mass effect on bilateral PA walls, tunnel-like narrowing of the right PA, and complete adherence of the PA to the aorta. The patient received a bypass from the right PA to the proximal main PA with immediate improvement in right ventricular and PA pressures. PA histopathology showed inflammatory infiltrate with small lymphoid cells on hematoxylin and eosin (H&E) staining (B). Immunohistochemical staining showed predominant T-cell infiltrate with robust CD3+ staining (C); lighter CD4+ (D), CD8+ (E), and CD20+ (F) staining; and negative IgG4 staining (G). Findings were consistent with vasculitis, and Takayasu arteritis was diagnosed. The patient received prednisone (40 mg/day) and tocilizumab (8 mg/kg monthly). After 6 months, she was asymptomatic, the prednisone had been tapered off, and repeat PET-CT showed marked interval decrease in hypermetabolic activity of the PA with a maximum SUV of 4.3 (H). Isolated PA involvement and pericarditis are rare initial Takayasu arteritis presentations (1, 2). Takayasu arteritis has been successfully treated with tocilizumab in case reports, leading to a small phase III trial showing a trend to improvement (3).

B-PO05-209 PERICARDIAL EFFUSION AFTER LEFT ATRIAL APPENDAGE OCCLUSION RESULTING FROM AN AORTIC DISSECTION

Atrial fibrillation (AF) affects 2.3 million Americans. In those unfit for long-term anticoagulation, left atrial appendage occlusion (LAAO) is an alternative for stroke prophylaxis. N/A N/A A 68-year-old female with a history of AF, 4.3 cm ascending aortic aneurysm, hemoptysis on anticoagulation, and an aspirin allergy successfully underwent a LAAO with a 27 mm Watchman device. Postoperatively, she developed a moderate pericardial effusion without tamponade physiology. The effusion and her 3.5 cm aortic root (Fig. 1A) remained stable after anticoagulation reversal and over 48-hour observation. Warfarin and clopidogrel were restarted at discharge. The patient was readmitted 48 hours later with back pain. She was diagnosed with a Stanford type A dissection from the aortic root to the renal arteries, with extension into the pericardial space without evidence of tamponade (Fig. 1B, C). Unlike previously reported post-LAAO effusions, this effusion was not caused by the LAAO device. It is most likely that the new initiation of anticoagulation and possible injury during catheter manipulation potentiated the propagation of a pre-existing aortic dissection. Cardiothoracic surgery was emergently consulted, but she suffered a cardiac arrest and expired prior to intervention. When evaluating a pericardial effusion after LAAO, the differential should extend past a procedural complication to include other life-threatening conditions, like an aortic dissection which was uniquely presented in this case. Peri-procedural echocardiograms should include an appraisal of the aortic root and ascending aorta to rule out acute pathology.

Usefulness of neutrophil-to-lymphocyte ratio for predicting acute pericarditis outcomes

Background In daily practice, C-reactive protein (CRP) may be used to predict recurrence and treatment response in patients with acute pericarditis; however, the predictive role of CRP might be insufficient for clinical prediction in some patients. In this study, we aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and the composite endpoint of pericarditis recurrence and/or tamponade within 1 year in patients with acute pericarditis. Methods A total of 104 patients diagnosed with acute idiopathic pericarditis (mean age 42.8 ± 15.2 years, 55.8% male) were included in the study. Physical examination findings of these patients, electrocardiography, echocardiography, chest X-ray and laboratory findings were evaluated and analysed. During the 1-year follow-up, the composite of cardiac tamponade and/or pericarditis recurrence was investigated as the primary endpoint of the study. Results Compared to the group without the composite outcome, the group with the composite outcome had significantly higher rates of moderate and severe pericardial effusion (p < 0.01) and higher white blood cell (WBC) count (p:0.001), platelet count (p = 0.003), NLR (2.14 (1.49–3.02) vs 6.60 (5.50–8.68); p < 0.001) and high-sensitivity C-reactive protein (hs-CRP) (8.01 (5.1–24.5 vs 69.5 (40.8–128); p:0.001). Higher hs-CRP (p < 0.001), WBC (p:0.001), NLR (p < 0.001) and platelets (p:0.02) were associated with pericarditis recurrence. NLR and hs-CRP were independently associated with the composite endpoint (p < 0.001 and p < 0.001, respectively). Conclusion NLR and hs-CRP were found to be independent predictors for the composite endpoint of tamponade and/or recurrence in acute pericarditis patients during the 1-year follow-up. Similar to hs-CRP, NLR may also be used for risk assessment in patients with idiopathic pericarditis.