New-onset Cardiomyopathy Research Articles

8081 Case report of sympathetic paraganglioma presenting as chronic catecholamine induced cardiomyopathy

Abstract Disclosure: Z. Tan: None. A. Taiwo: None. Background: Sympathetic paragangliomas are rare neuroendocrine tumors (<1/100,000) arising from extra-adrenal autonomic paraganglia, generally in the thorax, abdomen, and pelvis. They secrete catecholamines predominantly norepinephrine, which can cause a rare complication of catecholamine-induced cardiomyopathy. Clinical Case: A 33-year-old male, with history of obesity and borderline hypertension not on medication, presented with dyspnea on exertion, worsening paroxysmal nocturia dyspnea of 1 month duration and sudden onset of severe right flank pain. Work up for his chronic shortness of breath revealed: Troponin negative. EKG showed sinus tachycardia. Echocardiogram revealed enlarged left ventricle, severely decreased LV systolic function of 25-30%. Given the absence of angina symptoms, negative troponin, and EKG findings, his new-onset cardiomyopathy was presumed to be non-ischemic. CT chest, abdomen and pelvis was performed for the new onset right flank pain, which revealed a 4.1 cm x 4.0 cm centrally necrotic aortocaval soft tissue mass. This raise a concern about malignancy. A CT-guided Fine-Needle Aspiration of the retroperitoneal mass suggested paraganglioma. Further investigation showed plasma normetanephrine at 5.56 nmol/L (Reference range: 0-0.89 nmol/L), 24 hour urine normetanephrine at 2411 ug/d (Reference range: 114-865 ug/d), and 24 hour urine norepinephrine at 179 ug/d (Reference range: 14-20 ug/d). Plasma metanephrines and plasma dopamine were within the normal range. A gallium DOTATE PET/CT revealed a necrotic aortocaval mass with peripheral uptake, consistent with the known paraganglioma. He was diagnosed with sympathetic paraganglioma complicated with chronic catecholamine-induced cardiomyopathy and had exploratory laparotomy excision of his paraganglioma. Preoperatively, he was treated with phenoxybenzamine and carvedilol. However, his post-surgical course was complicated by acute on chronic heart failure and pneumonia, and he subsequently passed away from a pulseless electrical activity arrest. Conclusion: Although sympathetic paragangliomas rarely presents as catecholamine-induced cardiomyopathy, this case emphasizes the importance of considering hormonal abnormalities in patients who present with non-ischemic cardiomyopathy without high risk factors. Reference: 1. Alessandra Giavarini, Antoine Chedid et al. Acute catecholamine cardiomyopathy in patients with phaechromocytoma or functional paraganglioma. Heart 2013; 99: 1438-1444. Presentation: 6/2/2024

Association between positive serology for COVID-19 and chagas cardiomyopathy progression: The SaMi-Trop project

BackgroundChagas Disease (CD) can cause Chagas cardiomyopathy. The new coronavirus disease (COVID-19) also affects the cardiovascular system and may worsen Chagas cardiomyopathy. However, the cardiac evolution of patients with CD infected by COVID-19 is not known. Thus, the objective of this study is to assess, within one year, whether there was cardiac progression after COVID-19 in CD. MethodsLongitudinal study with CD patients. The outcome was cardiac progression, defined as the appearance of new major changes in the current ECG compared to the previous ECG considered from the comparison of electrocardiograms (ECGs) performed with an interval of one year. Positive Anti-SARS-CoV2 Serology was the independent variable of interest. For each analysis, a final multiple model was constructed, adjusted for sociodemographic, clinical, and pandemic-related characteristics. ResultsOf the 404 individuals included, 22.8 % had positive serology for COVID-19 and 10.9 % had cardiac progression. In the final model, positive serology for COVID-19 was the only factor associated with cardiac progression in the group as a whole (OR = 2.65; 95 % CI = 1.27–5.53) and for new-onset cardiomyopathy in the group with normal previous ECG (OR = 3.50; 95 % CI = 1.21–10.13). ConclusionOur study shows an association between COVID-19 and progression of Chagas cardiomyopathy, evaluated by repeated ECGs, suggesting that COVID-19 accelerated the natural history of CD.

A Novel ECG-Based Deep Learning Algorithm to Predict Cardiomyopathy in Patients With Premature Ventricular Complexes

BackgroundPremature ventricular complexes (PVCs) are prevalent and, although often benign, they may lead to PVC-induced cardiomyopathy. We created a deep-learning algorithm to predict left ventricular ejection fraction (LVEF) reduction in patients with PVCs from a 12-lead electrocardiogram (ECG). ObjectivesThis study aims to assess a deep-learning model to predict cardiomyopathy among patients with PVCs. MethodsWe used electronic medical records from 5 hospitals and identified ECGs from adults with documented PVCs. Internal training and testing were performed at one hospital. External validation was performed with the others. The primary outcome was first diagnosis of LVEF ≤40% within 6 months. The dataset included 383,514 ECGs, of which 14,241 remained for analysis. We analyzed area under the receiver operating curves and explainability plots for representative patients, algorithm prediction, PVC burden, and demographics in a multivariable Cox model to assess independent predictors for cardiomyopathy. ResultsAmong the 14,241-patient cohort (age 67.6 ± 14.8 years; female 43.8%; White 29.5%, Black 8.6%, Hispanic 6.5%, Asian 2.2%), 22.9% experienced reductions in LVEF to ≤40% within 6 months. The model predicted reductions in LVEF to ≤40% with area under the receiver operating curve of 0.79 (95% CI: 0.77-0.81). The gradient weighted class activation map explainability framework highlighted the sinus rhythm QRS complex-ST segment. In patients who underwent successful PVC ablation there was a post-ablation improvement in LVEF with resolution of cardiomyopathy in most (89%) patients. ConclusionsDeep-learning on the 12-lead ECG alone can accurately predict new-onset cardiomyopathy in patients with PVCs independent of PVC burden. Model prediction performed well across sex and race, relying on the QRS complex/ST-segment in sinus rhythm, not PVC morphology.

COVID-19 and Cardiomyopathy in African Americans: An Early Single-Center Experience.

Introduction The 2019 coronavirus pandemic has taken a toll on our society. Although most patients report minimal symptoms, a small proportion of patients have reported significant respiratory symptomsthat led to admission to the inpatient medical ward or even the intensive care unit. Complications and long-term sequela of COVID-19 are still being reported and studied. The presence of cardiomyopathy, whether established or new-onset and its effect on inpatient mortality, admission to the intensive care unit or length of stay hasn't been studied. Methods All inpatient hospitalizations in our database between March 1, 2020, and April 30, 2020, due to COVID-19 were reviewed. Patients who had at least a limited echocardiogram during this time were included in the study if they were above the age of 18. Patients were then assigned to three groups. The first group had patients with normal left ventricular systolic function. The second group had established cardiomyopathy that persisted throughout admission. The third group had patients who were found to have new-onset cardiomyopathy during admission. Results The inpatient mortality, although high and variable, wasn't significantly different between the three groups. Also, there was no significant difference between admission to the intensive care unit, disposition at discharge, or oxygenation status at 24 hours between the three groups. The length of stay in the established cardiomyopathy group was markedly lower, and we suspect that could be due to more aggressive discussions about end-of-life care. Conclusion Early COVID-19 experience at our center revealed a relatively high mortality rate that was primarily due to respiratory failure. The presence of established or new cardiomyopathy didn't appear to alter the outcomes significantly early in the pandemic.

Cardiac and inflammatory biomarker differences in adverse cardiac events after chimeric antigen receptor T-Cell therapy: an exploratory study

BackgroundChimeric antigen receptor T- Cell (CAR-T) immunotherapy has been a breakthrough treatment for various hematological malignancies. However, cardiotoxicities such as new-onset heart failure, arrhythmia, acute coronary syndrome and cardiovascular death occur in 10–15% of patients treated with CAR-T. This study aims to investigate the changes in cardiac and inflammatory biomarkers in CAR-T therapy to determine the role of pro-inflammatory cytokines.MethodsIn this observational study, ninety consecutive patients treated with CAR-T underwent baseline cardiac investigation with electrocardiogram (ECG), transthoracic echocardiogram (TTE), troponin-I, and B-type natriuretic peptide (BNP). Follow-up ECG, troponin-I and BNP were obtained five days post- CAR-T. In a subset of patients (N = 53), serum inflammatory cytokines interleukin (IL)-2, IL-6, IL-15, interferon (IFN)-γ, tumor necrosis factor (TNF)-α, granulocyte-macrophage colony-stimulating factor (GM-CSF), and angiopoietin 1 & 2 were tested serially, including baseline and daily during hospitalization. Adverse cardiac events were defined as new-onset cardiomyopathy/heart failure, acute coronary syndrome, arrhythmia and cardiovascular death.ResultsEleven patients (12%) had adverse cardiac events (one with new-onset cardiomyopathy and ten with new-onset atrial fibrillation). Adverse cardiac events appear to have occurred among patients with advanced age (77 vs. 66 years; p = 0.002), higher baseline creatinine (0.9 vs. 0.7 mg/dL; 0.007) and higher left atrial volume index (23.9 vs. 16.9mL/m2; p = 0.042). Day 5 BNP levels (125 vs. 63pg/mL; p = 0.019), but not troponin-I, were higher in patients with adverse cardiac events, compared to those without. The maximum levels of IL-6 (3855.0 vs. 254.0 pg/mL; p = 0.021), IFN-γ (474.0 vs. 48.8pg/mL; p = 0.006) and IL-15 (70.2 vs. 39.2pg/mL; p = 0.026) were also higher in the adverse cardiac events group. However, cardiac and inflammatory biomarker levels were not associated with cardiac events. Patients who developed cardiac events did not exhibit worse survival compared to patients without cardiac events (Log-rank p = 0.200).ConclusionAdverse cardiac events, predominantly atrial fibrillation, occur commonly after CAR-T (12%). The changes in serial inflammatory cytokine after CAR-T in the setting of adverse cardiac events suggests pro-inflammation as a pathophysiology and require further investigation for their role in adverse cardiac events.Tweet brief handleCAR-T related Cardiotoxicity has elevated cardiac and inflammatory biomarkers. #CARTCell #CardioOnc #CardioImmunology.

SGLT2 INHIBITOR USE IN HFPEF ASSOCIATED WITH SEVERE SEPSIS AND SEPTIC SHOCK AND A NEW ONSET CARDIOMYOPATHY

SGLT2 INHIBITOR USE IN HFPEF ASSOCIATED WITH SEVERE SEPSIS AND SEPTIC SHOCK AND A NEW ONSET CARDIOMYOPATHY

Abstract 14638: Survival Outcomes in Hospitalized COVID19 Patients With New Onset Cardiomyopathy

Introduction: Cardiac injury is known to occur in patients with COVID19 infection and is associated with a poor prognosis. However, there is limited data assessing the survival outcomes in hospitalized COVID19 patients with new-onset cardiomyopathy (NOC). We studied the impact of NOC on short and long term mortality in hospitalized COVID19 patients. Methods: We reviewed all cases of hospitalized COVID19 patients from the Cleveland Clinic COVID19 registry from 18 th March, 2020 to 18 th May, 2021 who received an in-hospital echocardiogram and had any prior echocardiogram to compare. The mean interval between the in-hospital and prior echocardiogram was 2.8 years. NOC was defined as a reduction in left ventricular ejection fraction (LVEF) of > 10% with a new LVEF of < 53%. The 30-day and 1-year mortality of patients with NOC were analyzed. Results: Of the 1537 hospitalized COVID19 patients receiving echocardiogram, 907 with a prior echocardiogram were included, of which 77 (8.5%) had NOC. Out of the 907 patients, 229 (25.2%) died within 30-days and 519 (57.2%) died within one year. It was found that patients with NOC had higher 30-day mortality than those without NOC (24.2% vs 36.4%, p=0.0078). However, the 1-year mortality was similar in the two groups (41.4% vs 45.3%, p=0.21). Conclusions: We found that NOC in hospitalized COVID19 patients was associated with higher 30-day mortality, however, it did not adversely impact the 1-year survival. Our findings suggest that although NOC is associated with worse short-term outcomes, long-term survival was primarily driven by the underlying disease process rather than the NOC.

Abstract 14645: Progression of Left Ventricular Ejection Fraction in Hospitalized COVID19 Patients With New Onset Cardiomyopathy

Introduction: New-onset cardiomyopathy (NOC) has been seen in hospitalized patients with COVID19 infection. Such NOC was associated with increased 30-day mortality. Long-term follow-up to assess the reversibility of such cardiomyopathy is lacking. We studied the follow-up echocardiograms in such patients and assessed the reversibility of their cardiomyopathy. Methods: We reviewed all cases of hospitalized COVID19 patients from the Cleveland Clinic COVID19 registry from 18 th March, 2020 to 18 th May, 2021. Patients who received an in-hospital echocardiogram and had echocardiogram prior to and post COVID19 hospitalization were selected for the study. NOC was defined as a reduction in left ventricular ejection fraction (LVEF) of > 10% with a new LVEF of < 53%. Cardiomyopathy was considered reversible if the follow-up echocardiogram showed an improvement in LVEF, with new LVEF >53%. The mean interval between the in-hospital and follow-up echocardiogram was 5.6 months. Results: Of the 1537 hospitalized COVID19 patients receiving echocardiogram, 907 had a prior echocardiogram, of which 77 (8.5%) had NOC. Patients with NOC were significantly more likely to be females and have chronic kidney disease. Of the 77 patients with NOC, 35 (45.5%) had follow-up echocardiograms. Of these, only 13 (37.1%) had reversible cardiomyopathy while 22 (62.9%) had persistently decreased LVEF. Conclusions: Our study highlights the lack of follow-up echocardiograms for patients with NOC and a persistence in decreased left ventricular systolic function in those that received one. All patients with NOC and COVID19 infection should receive follow-up echocardiography to guide their management.

Cardiac damage in an adolescent patient with COVID-19: a case report

COVID-19 has been found to affect the cardiovascular system leading to myocardial damage. A study of 41 patients in Wuhan, China, found that 12% of COVID-19 patients experienced virus-related acute cardiac damage.Subsequent bigger Chinese studies also found acute cardiac damage in 7.2% to 27.8% of hospitalized patients. As a chronicsequela, this condition may result in cardiomyopathy. We report acase of an adolescent COVID-19 survivor with dilated cardiomyopathy with no underlying heart disease. A male patient aged 16 years old was admitted to our outpatient clinic with the primary symptom of exhaustion and had recovered frommild to moderate COVID-19 one month prior to the visit. No previous history of heart disease was documented. Physical examination showed no abnormalities. Laboratory results revealed substantially elevated NT-proBNP (7705 pg/mL) and D-dimer (1850 ng/mL). ECG presented normal sinus rhythm with poorR wave progression. Echocardiography revealed all chamber dilatation, eccentric left ventricular hypertrophy, globalhypokinetic, moderate mitral regurgitation, and reduced ejection fraction (22%). We diagnosed the patient with new-onset dilated cardiomyopathy and began treatment with candesartan, bisoprolol, furosemide, spironolactone, rivaroxaban, and trimetazidine. The recovery was steady at three-month follow-up visit. The emergence of new-onset cardiomyopathy in this previously healthy adolescent raisesthepossibility of COVID-19 acting asthe sole cause of myocardial injuryin the absence of underlying heart disease. To avoid further complications, comprehensive evaluation and effective therapy should be implemented during hospitalization and post-discharge. Additional tests such as cardiac magnetic resonance imaging and endomyocardial biopsies shouldbe performed to support final proof.

An Unusual Case of Malignant Hypertension and Stress Cardiomyopathy

A 39-year-old man with chronic hypertension presented with perioperative malignant hypertension while undergoing induction for elective surgery. He was treated with intravenous antihypertensives. He reported several years of episodic chest pain, palpitations, and diaphoresis. Transthoracic echocardiogram demonstrated new-onset cardiomyopathy. Urinary and serum catecholamines were measured and the pattern of catecholamine levels suggested an extra-adrenal source. Computed tomography of the abdomen showed a contrast-enhancing mass in the bladder suspicious for metastatic paraganglioma. The patient had surgical resection with substantial improvement in his hypertension. The presence of labile hypertension and acute cardiomyopathy precipitated by stress should prompt evaluation for a catecholamine-producing tumor and appropriate genetic testing.

C74. Post covid-19 cardiomyopathy in an adolescent patient: a case report

Abstract Background Myocardial injury caused by viral myocarditis may occur during COVID-19 infections. This condition may lead to cardiomyopathy as the chronic sequela. We report a case of an adolescent COVID-19 survivor without underlying heart disease presented with dilated cardiomyopathy. Case Summary A 16-year-old male patient was referred to Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto. The patient presented with a chief complaint of fatigue and just recovered from mild to moderate COVID-19 one month before the visit. There was no prior history of heart disease. Physical examination was within normal limit, but laboratory findings showed highly elevated NT-proBNP (7705 pg/mL) and D-dimer (1850 ng/mL). ECG revealed normal sinus rhythm with poor R wave progression. Echocardiography detected all chamber dilatation, eccentric left ventricular hypertrophy, global hypokinetic, moderate mitral regurgitation, and reduced ejection fraction (22%). The patient was diagnosed with new-onset dilated cardiomyopathy as a COVID-19 sequela and we initiated treatment with ARB (candesartan), beta-blocker (bisoprolol), diuretics (furosemide and spironolactone), rivaroxaban, and trimetazidine. During a follow-up visit three months later, the patient’s recovery was stable. Discussion The occurrence of new-onset cardiomyopathy in our previously healthy young patient highlights the possible mechanism of COVID-19 as a single cause of myocardial injury without underlying heart disease. Comprehensive evaluation and optimal treatment should be taken during hospitalization and post-discharge period to prevent further complications. Additional examinations such as cardiac magnetic resonance and endomyocardial biopsy should be done to provide definitive confirmation.

C74. Post covid-19 cardiomyopathy in an adolescent patient: a case report

BackgroundMyocardial injury caused by viral myocarditis may occur during COVID-19 infections. This condition may lead to cardiomyopathy as the chronic sequela. We report a case of an adolescent COVID-19 survivor without underlying heart disease presented with dilated cardiomyopathy. Case SummaryA 16-year-old male patient was referred to Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto. The patient presented with a chief complaint of fatigue and just recovered from mild to moderate COVID-19 one month before the visit. There was no prior history of heart disease. Physical examination was within normal limit, but laboratory findings showed highly elevated NT-proBNP (7705 pg/mL) and D-dimer (1850 ng/mL). ECG revealed normal sinus rhythm with poor R wave progression. Echocardiography detected all chamber dilatation, eccentric left ventricular hypertrophy, global hypokinetic, moderate mitral regurgitation, and reduced ejection fraction (22%). The patient was diagnosed with new-onset dilated cardiomyopathy as a COVID-19 sequela and we initiated treatment with ARB (candesartan), beta-blocker (bisoprolol), diuretics (furosemide and spironolactone), rivaroxaban, and trimetazidine. During a follow-up visit three months later, the patient’s recovery was stable.Discussion The occurrence of new-onset cardiomyopathy in our previously healthy young patient highlights the possible mechanism of COVID-19 as a single cause of myocardial injury without underlying heart disease. Comprehensive evaluation and optimal treatment should be taken during hospitalization and post-discharge period to prevent further complications. Additional examinations such as cardiac magnetic resonance and endomyocardial biopsy should be done to provide definitive confirmation.

Abstract 12091: Incidence and Predictors of Progression to Chagas Cardiomyopathy: Long-Term Follow-Up of a Large Cohort of Trypanosoma cruzi- Infected Individuals

Introduction: There are few contemporary prospective cohorts of Trypanosoma cruzi ( T.cruzi )-infected individuals. This study aimed to determine the incidence of new-onset cardiomyopathy and death attributable to T. cruzi infection. Methods: We enrolled 1088 individuals: 499 T. cruzi -seropositive blood donors identified in routine donor screening, 488 age- and sex-matched T. cruzi - seronegative blood donors, and 101 patients with established Chagas cardiomyopathy recruited from a tertiary center. Subjects underwent cardiovascular evaluation with ECG and echocardiogram at the baseline (2008-2010) and follow-up (2018-2019) visits. Cardiomyopathy was diagnosed based on ECG and echocardiographic findings at baseline and follow-up. Vital status was determined by linkage with the national Brazilian mortality system. Results: Mortality was 80.9 deaths/1000 person-years (py) in established cardiomyopathy and 15.1 deaths/1000py in T. cruzi -seropositive donors with cardiomyopathy at baseline. The mortality rate among T. cruzi -seropositive blood donors without cardiomyopathy at baseline and T. cruzi -seronegative controls was similar, with mortality rates of 3.67 and 3.62 events/1000 py, respectively. In T. cruzi -seropositive donors, age (hazard ratio [HR] = 1.05 per year), anti-T.cruzi antibody level (HR = 1.40 per unit increase in serology assay signal/cut off) and the presence of cardiomyopathy at baseline (HR = 3.01) were independent predictors of mortality. The incidence of new-onset cardiomyopathy in T. cruzi -seropositive donors was 13.8 events/1000 py (95% CI 9.5-19.6) compared with 4.6 events/1000 py (95% CI 2.3-8.3) in controls, with an absolute incidence difference attributable to T. cruzi infection of 9.2 (95% CI 3.6 - 15.0) events/1000py. T. cruzi antibody level at baseline was the main independent predictor of subsequent new-onset cardiomyopathy with an adjusted odds ratio of 1.37 (95% CI 1.07-1.76) per unit increase in antibody level. Conclusions: We present a comprehensive description of the natural history of T. cruzi infection in a contemporary patient population. The results highlight the central importance of total anti- T. cruzi antibody titer as a marker of Chagas disease activity and risk of progression.

February 2021 at a glance: focus on amyloidosis, myocarditis and cardiomyopathy

Cardiac amyloidosis (CA) is emerging as a major cause of heart failure (HF).1-3 Castiglione et al.4 reviewed the role of circulating biomarkers as tools to guide diagnosis, prognostic stratification, and therapy in CA. The independent prognostic role of cardiopulmonary exercise testing in patients with light chain or transthyretin CA (TTR-CA) was shown by Nicol et al.5 in a multicentre study. Both peak oxygen consumption (VO2) ≤13 mL/kg/min and N-terminal pro B-type natriuretic peptide (NT-proBNP) ≥1800 ng/L had independent prognostic value with a hazard ratio (HR) of 2.7 [95% confidence interval (CI) 1.6–4.8] and 2.2 (95% CI 1.1–4.3), respectively. No events occurred in patients with peak VO2 >13 mL/kg/min and NT-proBNP <1800 ng/L during a median follow-up of 20 months, despite overall 25% mortality and 29% hospitalization rates. Amyloidosis may be present in patients with severe aortic stenosis.2, 6 TTR-CA was detected in 13% of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. It had no impact on mortality but was associated with a higher HF hospitalization rate during a 3-year follow-up.3 Tafamidis has emerged as an effective treatment option to improve prognosis in patients with TTR-CA.7, 8 A single-centre study in 648 real-world patients with TTR-CA matching the inclusion criteria of the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) showed a significant benefit of tafamidis on major cardiovascular outcomes (HR after propensity score matching 0.546, P = 0.0132).9 In an analysis of the long-term extension of ATTR-ACT, both tafamidis 80 mg and 20 mg reduced all-cause mortality and cardiovascular hospitalizations at 30 months compared with placebo, with the higher dose associated with better outcomes without safety issues in the long-term extension.10 Sinagra et al.11 reviewed data about the role of viral detection for immunomodulation in acute lymphocytic myocarditis, highlighting current limitations of this approach and providing a framework for future dedicated studies. The Authors pointed out that the value of viral presence to guide immunosuppressive treatment in lymphocytic myocarditis requires more evidence and remains a subject of debate. As a further support, intravenous immunoglobulin did not improve cardiac systolic function or functional status in patients with chronic inflammatory cardiomyopathy, namely idiopathic dilated cardiomyopathy with parvovirus B19 persistence, in a randomized controlled trial.12 Over the last years, improvement in survival was observed in patients with dilated cardiomyopathy, with many patients with new-onset cardiomyopathy who may show reverse remodelling.13, 14 In TRED-HF, withdrawal of pharmacological treatment for HF in patients with recovered dilated cardiomyopathy was associated with relapses in 44% of patients.15 In a further analysis by cardiac magnetic resonance, treatment withdrawal resulted in early ventricular remodelling with an increase in myocardial mass and a reduction in global longitudinal strain. Interestingly, these changes may also occur in patients who do not show clinical deterioration.16 Shorter left ventricular systolic ejection time has been identified as a marker of worse prognosis among patients with HF with reduced ejection fraction (HFrEF).17 Alhakak et al.18 confirmed the prognostic impact of left ventricular systolic ejection time on mortality in a large HFrEF population (per 10 ms decrease: adjusted HR 1.06, 95% CI 1.01–1.11, P = 0.030), hence supporting its use to stratify patients' risk and to guide therapeutic response. Heightened chemosensitivity has a major role in the excessive ventilatory response to exercise and sleep breathing abnormalities in patients with HF. Buspirone, a 5HT1A receptor agonist that inhibits serotonergic chemoreceptor neuron firing, reduced carbon dioxide chemosensitivity and improved central apnoeas in patients with HF.19 A relatively large number of patients with advanced HF may benefit from long-term mechanical circulatory support.20 This indication might be further expanded if this device therapy may cause regression of myocardial fibrosis. Unfortunately, such hypothesis was not proven in a recent study in 125 patients.21

The Prevalence and Short-Term Outcomes of Ventricular Dyssynchrony after Right Ventricular Pacing

Objective: Long-term right ventricular pacing has been associated with an increased risk of heart failure and cardiomyopathy. The pathophysiology of cardiomyopathy associated with right ventricular pacing remains unclear. We aim to evaluate the burden and short-term outcomes of ventricular dyssynchrony after immediate permanent pacemaker implantation. Materials and Methods: This prospective cohort study examined consecutive patients who had permanent pacemaker implantation at Vajira Hospital in 2019. Left ventricular systolic function, specifically left ventricular ejection fraction (LVEF) and echocardiographic ventricular dyssynchrony parameters were assessed. The endpoints included the prevalence of ventricular dyssynchrony, new-onset cardiomyopathy, heart failure, and death. The correlation between QRS complex duration, the burden of ventricular pacing, and echocardiographic ventricular dyssynchrony was measured. Results: Thirty-six consecutive patients underwent pacemaker implantation. The prevalence of mechanical ventricular dyssynchrony was 22.2% using the interventricular conduction delay method, 41.7% using LV pre-ejection period method, and 11.1% using the septal posterior wall motion abnormality method. Electrical ventricular dyssynchrony was 86.1% and new-onset cardiomyopathy was 17.1% after 3 months of permanent pacemaker implantation. The right ventricular pacing of more than 20% was significantly associated with cardiomyopathy (p < 0.022) and heart failure (log-rank, p = 0.049) within 3 months. But heart failure was not associated with mechanical ventricular dyssynchrony parameters (log-rank, p = 0.610; hazard ratio [HR], 1.53; 95% confidence interval [CI], 0.29 - 7.96; p = 0.613 for IVMD and log-rank, p = 0.398; HR, 0.04; 95% CI, 0.01 - 3316.7 for SPWMD). Conclusion: Mechanical and electrical ventricular dyssynchrony are common findings in right ventricular pacing. High-burden right ventricular pacing after 3 months of permanent pacemaker implantation is often associated with cardiomyopathy and heart failure, but mechanical and electrical ventricular dyssynchrony does not predict a short-term decline in left ventricular systolic function and heart failure.

New-onset Heart Failure With Atrial Fibrillation: A Distinct Type of Cardiomyopathy?

There is limited research comparing demographic and clinical characteristics between patients who present with atrial fibrillation (AF) and new-onset cardiomyopathy (CM) to patients with new-onset CM without dysrhythmia. We aimed to evaluate clinical characteristics and outcomes in patients with new-onset CM with and without AF and to report their real-world treatment. The study population was identified using patient records from our healthcare system from January 1, 2012 to September 30, 2016. Patients with a left ventricular ejection fraction ≤40% without a prior history of CM were divided into two groups; those with an antecedent or concomitant diagnosis of AF (AF-CM group) and those with no history of dysrhythmia (CM group). Patients in the AF-CM group (n=196) were older, more likely to be male, had a higher burden of comorbidities but lower levels of cardiac biomarkers, and had lower voltage on surface electrocardiogram than the CM group (n=197). In AF-CM, symptom onset was insidious, leading to a higher likelihood of outpatient diagnosis; 88.3% of AF-CM patients presented with atypical symptoms of AF. The AF-CM group had higher mortality on follow-up. Only 8.7% of patients in this group underwent an ablation procedure. Women, those with a history of coronary artery disease, and older patients were less likely to receive a cardioversion or ablation procedure. Patients presenting with new-onset CM associated with AF have a markedly different risk factor and demographic profile, clinical presentation, and outcomes. In real-world practice, a minority of patients undergo a rhythm control strategy.

Incidence, Predictors, and Outcomes of New-Onset Left Ventricular Systolic Dysfunction After Orthotopic Liver Transplantation

Adverse cardiovascular events after liver transplantation (LT) are relatively common and are a significant source of early mortality. Although new-onset systolic dysfunction after LT is a reported phenomenon, there is little data regarding its incidence, risk factors, and outcomes. This single-center retrospective study included all adult patients from January 2002 to March 2015 with deceased-donor LT and available preoperative transthoracic echocardiograms (TTEs). In total, 1,760 patients were included in the study, 602 (34.2%) of whom had a postoperative TTE. The primary end point was development of new-onset cardiomyopathy, defined as a new left ventricular ejection fraction (LVEF) of <40% within 180days of transplant. Sixty-nine (11.4%) of the patients who received post-LT TTE had a reduction in LVEF to <40% within 6 months. Clinical parameters of donor and recipient did not show significant impact on development of post-LT LV systolic dysfunction (LVSD). Presence of wall motion abnormalities (P = .004) on preoperative TTE was predictive of development of post-LT LVSD. These patients did not have longer hospitalizations, but they had worse survival. Post-LT LV systolic dysfunction occurs at higher rates than previously suspected and may develop more frequently in patients with underlying cardiac structural abnormalities, which appear to adversely affect post-LT survival.

New-Onset Cardiomyopathy With and Without Atrial Fibrillation

Background: Atrial fibrillation (AF) is the most common arrhythmia and is often associated with cardiomyopathy (CM) and heart failure. There has been little research performed to assess whether there are any differences in patient profile, comorbidities, presenting complaints, and electrocardiographic (ECG) or laboratory characteristics and outcomes between patients who have AF at presentation or preceding the diagnosis of new-onset CM (defined as left ventricular ejection fraction ≤ 40%) and patients who are diagnosed with new-onset CM without any preceding atrial dysrhythmias.

When A Toxic Thyroid Makes The Liver Toxic: A Case Of Thyroid Storm Complicated By Acute Liver Failure

ABSTRACT Objective: Thyroid storm is a rare life-threatening medical emergency. It is associated with high mortality (10 to 30%). Though there may be mild derangements in liver function tests (LFTs), acute liver failure (ALF) is infrequently reported and its pathophysiology is poorly understood. We hereby report a case of ALF in a patient with thyroid storm. Methods: A 41-year-old female with history of Graves disease (non-compliant with treatment) complicated by multiple episodes of thyroid storm and atrial fibrillation (Afib) presented with exertional dyspnea and productive cough. She was found to be in Afib with rapid ventricular rate and new-onset cardiomyopathy (left ventricular ejection fraction of <20%). She was noted to have a large, non-tender thyroid gland with bruit; thyroid function tests were consistent with uncontrolled hyperthyroidism. Results: Two days after initiating treatment with methimazole and propranolol, she became increasingly lethargic, confused, and developed asterixis and icter...

Demographic features and prevalence of myocarditis in patients undergoing transarterial endomyocardial biopsy for unexplained cardiomyopathy.

BackgroundThe diagnosis of myocarditis is still a challenge. The true incidence of the disease is unknown due to great variation in clinical manifestations.ObjectiveThe aim of this study was to identify the demographic features and in-hospital prevalence of myocarditis in patients undergoing transarterial endomyocardial biopsy (EMB) for unexplained cardiomyopathy.Patients and methodsThis was a prospective observational study. We recruited all patients with unexplained cardiomyopathy presented at Assiut University Hospital from January 2014 till December 2014. The inclusion criteria were namely acute symptoms of heart failure, worsening of ejection fraction (EF) despite optimized therapy, hemodynamically significant arrhythmias, heart failure with concurrent rash, fever, or peripheral eosinophilia and new-onset cardiomyopathy in the presence of known amyloidosis. We excluded patients with uncontrolled hypertension, diabetes mellitus, ischemic, congenital, rheumatic heart disease, peripartum cardiomyopathy, cardiotoxic exposure, alcoholic and familial cardiomyopathies. All patients were subjected to full examination with ECG, echocardiography and coronary angiography, and then 3 EMB samples via femoral artery were taken from the LV. The histopathological examination of all biopsies was done.ResultsOut of the 1100 patients admitted to our department, 15 patients (1.4%), who had unexplained cardiomyopathy were included in our study. Seventy-three percent were males with mean age 37.8 ± 17 y. 87% were from rural areas, and 73.3% presented with dyspnea grade III to IV for a duration period that varied from 2 to 8 weeks. 33% had an EF > 40%. 33 EMB samples from 11 patients were examined. 7 out of 11 patients (63.6%) proved to have myocarditis on pathological examination, 5 of them had active myocarditis, 1 had chronic myocarditis and 1 had borderline myocarditis. Three patients (27.3%) had no pathological evidence of inflammation and one patient (9.1%) had cardiac amyloidosis. Four out of 15 patients (26.7%) did not undergo EMB because of LV thrombus or bleeding tendency. None of our patients had any complication from EMB.ConclusionThe in-hospital prevalence of myocarditis is high among patients with unexplained cardiomyopathy. EMB via femoral artery is safe and essential in confirming the diagnosis.