Rapid Ventricular Rate Research Articles

A Systematic Review of Weight-Based Metoprolol for Acute Atrial Fibrillation with Rapid Ventricular Rate.

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in the emergency department (ED) and when patients present in acute AF with rapid ventricular rate (RVR), it can result in significant morbidity and mortality. Primary treatment modalities are aimed at rate control with the two most common agents being intravenous metoprolol and diltiazem. Some evidence suggests that diltiazem may be more effective at controlling rate in these patients; however, the dosing strategies, pharmacologic differences, and study designs may play a role in the observation of these differences. The purpose of this article is to review the evidence for using weight-based metoprolol in the treatment of AF with RVR. The vast majority of studies comparing metoprolol and diltiazem for the treatment of acute AF with RVR compare a flat dose of metoprolol to a weight-based dose of diltiazem. Following a comprehensive review, only two studies have compared a weight-based dosing strategy of intravenous (IV) metoprolol versus IV diltiazem for this disease state. Overall, the two studies only contained 94 patients and failed to meet power. Beyond differing dosing strategies, differences in pharmacokinetics between the two medications (like the onset of action and metabolism) could have played a role in the differences observed in the studies. Further studies are warranted to provide better guidance on which agent should be used in the treatment of acute AF with RVR.

Brady- and tachyarrhythmias detected by continuous rhythm monitoring in paroxysmal atrial fibrillation

ObjectiveAtrial fibrillation (AF) is associated with adverse events including conduction disturbances, ventricular arrhythmias and sudden death. The aim of this study was to examine brady- and tachyarrhythmias using continuous rhythm...

Case Study of Biatrial Thrombus: Found Down With Atrial Fibrillation

BackgroundBiatrial thrombus is a rare condition that is typically associated with a patent foramen ovale (PFO). Case ReportThis is a case of a 75-year-old man with history of heavy alcohol use found down with altered sensorium. He was hypothermic and in atrial fibrillation with rapid ventricular rate and was subsequently found to have a biatrial thrombus with no evidence of PFO. Why Should an Emergency Physician Be Aware of This?Biatrial thrombus presents the unique danger of progressing to both pulmonary embolus and acute embolic disease (including stroke); both are life-threatening diagnoses that can be prevented by means of identifying and treating this rare and dangerous condition.

130: CALCIUM CHANNEL BLOCKERS VERSUS BETA BLOCKERS FOR ACUTE RATE CONTROL IN HEART FAILURE PATIENTS

Introduction: A rate control strategy is often pursued for management of new-onset atrial fibrillation and a rapid ventricular rate (RVR) in heart failure with reduced ejection fraction (HFrEF) patients. Either a beta blocker (BB) or non-dihydropyridine calcium channel blocker (non-DHP CCB) can be used, however, non-DHP CCBs may worsen heart failure through negative inotropic effects. This study was conducted to compare short-term use of BBs with non-DHP CCBs on the incidence of heart failure exacerbation. Methods: This was a multi-site, retrospective cohort study conducted at a 2,247-bed community teaching hospital system in the United States. Adult patients presenting to the emergency department for atrial fibrillation with RVR were included if they had new-onset or a history of HFrEF and received a non-DHP CCB or BB for less than 48 hours. Hemodynamically unstable patients were excluded. The primary outcome was the incidence of heart failure exacerbation within 48 hours of drug administration, defined by a combination of provider documentation and at least one clinical or laboratory marker. Additional efficacy and safety endpoints were assessed secondarily. Results: Between March 2018 and January 2021, 1,519 patients were screened and 164 included (113 in the non-DHP CCB group and 51 in the BB group). The median age was 70 years and 70% were male. The median dose of non-DHP CCB at 48 hours was 90 mg and the median duration was 13 hours. In the BB group, the median dose and duration was 5 mg and 6 hours, respectively. Eleven patients receiving a non-DHP CCB and 1 patient receiving a BB met the primary outcome (p=0.08). Patients who had a heart failure exacerbation in the non-DHP CCB group received both a higher median dose (190 mg) and longer median duration (21 hours) of therapy. Additionally, 6 patients in the non-DHP CCB group and 1 in the BB group experienced an exacerbation within 7 days (p=0.33). More patients in the non-DHP CCB group experienced bradycardia (23% vs 5.9%, p=0.008), however, there were no other differences in safety or efficacy. Conclusions: While not statistically significant, there were numerically more incidences of heart failure exacerbations in HFrEF patients receiving non-DHP CCBs compared with BBs for acute rate control.

151: PLANT PATHOGENS CAUSING PERICARDITIS

Introduction: Typical organisms associated with purulent pericarditis include numerous bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, Mycobacterium tuberculosis, Salmonella sp., and anaerobes, as well as various fungal organisms. We present an unusual case of pericarditis resulting from Burkholderia spp. Description: 79-year-old male with history of esophageal cancer (8 years ago, status post chemotherapy and radiation, currently in remission), esophageal stricture (status post stent placement), atrial fibrillation, arthritis, hypothyroidism, and anemia presented with fatigue, poor oral intake, lethargy, shortness of breath and productive cough. On arrival, he was hypotensive with focused cardiac ultrasound demonstrating a large circumferential pericardial effusion with right ventricular diastolic collapse and arterial line showing pulsus paradoxus on waveform analysis. White cell count was 11.62 k/mm3, hemoglobin 12.7 g/dl, potassium 7.1 mEq/L, bicarbonate 15.8 mEq/L, blood urea nitrogen 158 mg/dl, creatinine 7.79 mg/dl, brain natriuretic peptide 23,141 pg/ml. Computed tomography scan showed large pericardial effusion, bilateral pleural effusions and ascites which was confirmed on transthoracic echocardiogram (along with tamponade physiology). Empiric antibiotics, intravenous fluids and renal replacement therapy were started. Pericardiocentesis was performed (with removal of 200 ml of purulent fluid) and bilateral chest tubes were inserted. Pericardial fluid analysis showed 497,520 white cells/mm3; culture grew pansensitive Burkholderia gladioli/glumae/plantarii; fungal/tubercular cultures were negative, and cytology did not show any malignant cells. Course complicated by shock needing vasopressors and atrial fibrillation with rapid ventricular rate. Given worsening clinical condition, the patient opted for comfort care measures and succumbed to his illness shortly thereafter. Discussion: Burkholderia plantarii/glumae/gladioli are gram negative bacilli which are mainly pathogenic for plants. They have been shown to cause respiratory infections in cystic fibrosis and lung transplant patients. This patient with complex esophageal issues demonstrates an exceedingly rare case of Burkholderia-associated purulent pericarditis resulting from common rice pathogens.

Abstract 14401: A Rare Case of Patent Foramen Ovale Thrombus Caught in Transit

Introduction: Patent foramen ovale (PFO), seen in about 20-25% of the population, is linked with paradoxical embolism. However, a paradoxical thrombus seen in transit through a PFO is an extremely rare finding. Case: An 80-year-old-female with a history of stroke, atrial fibrillation (AF), and diabetes presented with a complaint of dizziness. She had a history of non-compliance with her anticoagulation for AF. EKG showed AF with rapid ventricular rate. An echocardiogram showed a large mobile thrombus in both atria representing a paradoxical embolus in transit caught in PFO (Figure A). Right ventricular systolic function was noted to be severely reduced. A transesophageal echocardiogram confirmed a paradoxical embolus in transit with a large amount of mobile thrombus in the left atrium (Figure B, C). Large saddle acute pulmonary embolus, extending bilaterally into main, lobar, and segmental pulmonary arteries, was seen on the CT chest (Figure D). Lower extremity ultrasound revealed right popliteal vein thrombosis extending to the peroneal vein. Due to a high risk of paradoxical systemic embolism patient underwent emergent surgical thrombectomy along with the closure of PFO. Conclusion: Paradoxical thrombus in transit through PFO carries a high risk of systemic embolism. Therapeutic options for patients include cardiac surgery with thrombectomy, thrombolysis, or systemic anticoagulation, with no clear consensus regarding the best treatment option.

Abstract 15712: Imaging Conundrum: The Diagnosis of Unusual Partial Anomalous Pulmonary Venous Return With Dual Connections

Case: A 68 year old male with a past medical history of hypertension, hyperlipidemia and chronic kidney disease presented for progressive dyspnea on exertion and bilateral lower extremity edema over three weeks. He was found to be in decompensated heart failure and new onset Atrial Flutter with rapid ventricular rate. Transthoracic echocardiography revealed severely impaired left ventricular systolic function with ejection fraction <20%, enlarged right ventricle, moderate right ventricular systolic dysfunction, biatrial enlargement, mild pulmonary hypertension. He was started on guideline directed medical therapy and referred for transesophageal echocardiogram (TEE) with cardioversion for new onset Atrial Flutter and possible tachycardia induced cardiomyopathy. Imaging findings: During TEE, routine doppler of right upper pulmonary vein showed markedly dilated superior vena cava (SVC) (3.6 cm) and unusual predominant outflow with brief mid late systolic inflow (Fig A and B), suggestive of partial anomalous pulmonary venous return (PAPVR). All three other pulmonary veins appeared normal. Also noted to have positive bubble study likely related to PAPVR. Subsequent right heart catheterization left to right shunt with Qp/Qs 1.6, step up noted between SVC and right atrium. CTA revealed partial anomalous right upper lobe pulmonary vein (RUPV) had dual connection to both SVC via window like communication and left atrium (Fig C), no sinus venosus defect seen. Conclusion: This case illustrates an unusual example of PAPVR with bidirectional flow, as well as the importance of thorough evaluation even on routine transesophageal echocardiograms especially for patients with right heart enlargement.

Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis

BackgroundIntravenous calcium channel blockers or beta-blockers are the preferred rate control medications for hemodynamically stable patients with atrial fibrillation with rapid ventricular rate (AF-RVR) in the emergency department. ObjectivesTo compare the efficacy of intravenous diltiazem and metoprolol for rate control and safety with respect to development of hypotension and bradycardia in patients with AF-RVR. MethodsFor this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane databases, and the clinicaltrials.gov registry between database inception and 30th May 2021. Articles were included if they compared efficacy and safety of diltiazem versus metoprolol in critically ill adult patients hospitalized with AF-RVR. Outcome measures were achievement of rate control, development of new hypotension, and bradycardia after drug administration. ResultsOf 86 records identified, 14 were eligible, all of which had a low to moderate risk of overall bias. The meta-analysis (Mantel-Haenszel, random-effects model) showed that diltiazem use was associated with increased achievement of rate control target compared to metoprolol [14 studies, n = 1732, Odds Ratio (OR): 1.92; 95% Confidence Intervals (CI):1.26 to 2.90; I2 = 61%]. In the pooled analysis, no differences were seen in hypotension using diltiazem vs metoprolol [12 studies, n = 1477, OR: 0.96; 95% CI:0.61 to 1.52; I2 = 35%] or bradycardia [9 studies, n = 1203, OR: 2.44; 95% CI: 0.82 to 7.31; I2 = 48%]. ConclusionsIntravenous diltiazem is associated with increased achievement of rate control target in patients with AF-RVR compared to metoprolol, while both medications are associated with similar incidence of hypotension and bradycardia.

LBODP071 Early Detection Of Immune-mediated Hypophysitis With Use Of Checkpoint Inhibitor Immunotherapy

Abstract Hypophysitis is an inflammatory infiltration of the pituitary gland. Association with cytotoxic T-lymphocyte antigen 4 (CTLA-4) targeting was described with a recommendation of discontinuing the treatment in such conditions . Hypophysitis has become more prevalent with increased use of immune checkpoint inhibitors with late detection being associated with a high morbidity and mortality. Symptomatic presentation, along with hemodynamic and serum abnormalities warrant urgent intervention as early measures prevent progression. This case is about a 60-year-old female with metastatic renal clear cell carcinoma status post right radical nephrectomy on combined nivolumab and ipilimumab (NIVO/IPI) and history notable for persistent atrial fibrillation on warfarin presented to the hospital after a fall. Eight days after her second cycle on NIVO/IPI, the patient developed hot flashes, vomiting, weakness, and vertiginous symptoms. Her exam was notable for atrial fibrillation with rapid ventricular rate and hypotension. Serology was notable for a sodium of 119 mEq/mL, prompting admission to the hospital. Due to high clinical suspicion for hypophysitis based on serological findings, the patient was given a dose of methylprednisolone then daily hydrocortisone to reverse the pituitary inflammation. Fludrocortisone was started for adrenal insufficiency. MRI of the brain with IV contrast was notable for abnormal enhancement and thickening of the pituitary stalk concerning for hypophysitis. The patient clinically improved with resolution of her dizziness, hot flashes, and vomiting. Her serum sodium improving to 132 mEq/mL. She was discharged home with immunotherapy held. Hypophysitis is a rare inflammatory disease affecting 1 in 7 million. Typical symptoms include headache, vision changes, fatigue, and hypopituitary deficiencies. Reported immunotherapies with incidences of secondary hypophysitis include CTLA-4 and PD-1 therapeutics. Immunotherapy associated hypophysitis occurs in <7% of patients. Hypophysitis is diagnosed by laboratory findings and imaging which can identify this acute process via enhancement and swelling of the pituitary gland . Management modalities include surgery, anti-inflammatory therapy, and conservative therapy. Medical management is mainly directed at the correction of pituitary hormone deficiencies and reduction of pituitary inflammation using glucocorticoid therapy . Presentation: No date and time listed

PSAT324 Altered Mental Status, Hypercalcemia, and Atrial Fibrillation Induced by Post-Parathyroidectomy Thyroiditis

Abstract Background Parathyroidectomy-induced thyroiditis is a rare but possibly underreported phenomenon. It has been reported in primary, secondary, and tertiary hyperparathyroidism, and typically presents with transient thyrotoxicosis in the days to weeks following surgery. Clinical Case A 66-year-old man with end stage renal disease complicated by tertiary hyperparathyroidism and no prior history of thyroid disease or cardiac dysrhythmia was admitted for parathyroidectomy. A multinodular goiter and four enlarged parathyroid glands were identified intraoperatively. With significant thyroid retraction, removal of the inferior parathyroid glands, left superior parathyroid gland, and one-half of the right superior parathyroid gland was successfully performed without complication. Despite normalization of the parathyroid hormone level after surgery, the patient's preoperative hypercalcemia was noted to paradoxically worsen, rising from a corrected total calcium of 10.9 mg/dL (ref. 8.5-10.4 mg/dL) to 12.2 mg/dL. This was observed concurrently with the development of worsening mental status and new onset atrial fibrillation with rapid ventricular rate, prompting beta blockade initiation. Administration of intravenous crystalloid and subcutaneous calcitonin rapidly normalized his serum calcium but did not resolve the altered mentation or cardiac arrhythmia. Thyroid function tests revealed thyroid stimulating hormone 0.05 mIU/L (ref. 0.49-4.67 mIU/L), free thyroxine (T4) 3.8 ng/dL (ref. 0.7-1.9 ng/dL), and total triiodothyronine 144 ng/dL (ref. 60-181 ng/dL). Thyroid stimulating immunoglobulin was negative, and a thyroid ultrasound demonstrated multiple bilateral thyroid nodules with no evidence of increased vascularity of the gland. Serial thyroid function tests over several days revealed spontaneous biochemical improvement in the patient's T4-thyrotoxicosis that correlated with improved mentation. An exhaustive metabolic, infectious, and radiologic work-up yielded no alternative explanation for his initial change in mental status. By postoperative day 6, his cardiac dysrhythmia and altered mentation completely resolved, and the free T4 improved to 2.1 ng/dL, allowing for hospital discharge. His free T4 normalized a week later. Conclusion Our patient's postoperative course appears to have been driven by surgically induced thyroiditis. There are no current recommendations for routine postoperative screening for parathyroidectomy-induced thyroiditis, but biochemical testing should be considered if signs or symptoms of thyrotoxicosis such as unexplained altered mentation, cardiac dysrhythmias, and/or worsening hypercalcemia emerge. Doing so may allow for a rapid and cost-effective approach towards a unifying diagnosis. Bilateral cervical exploration is a known risk factor. Other possible risk factors include the presence of a multinodular goiter and significant intraoperative thyroid retraction, though further characterization of these is needed. Treatment is supportive, as cases typically self-resolve. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT335 Histopathological changes of the thyroid may be subtle yet important in Amiodarone induced thyrotoxicosis (AIT).

Abstract Background Amiodarone is an effective antiarrhythmic for several cardiac arrhythmias. Due to its high iodine content and long half-life with direct toxic effects on the thyroid gland, it is known to cause a spectrum of thyroid dysfunction. AIT type 1, a form of iodine-induced hyperthyroidism, and AIT type 2, a drug induced destructive thyroiditis, pose a diagnostic and therapeutic challenge. Since the physical and psychological consequences of long-term therapy with either condition are too large to ignore, it is crucial to differentiate between the two types. Histopathologic findings in AIT includes disrupted follicles filled with desquamated vacuolated epithelial cells, foamy macrophages, scattered lymphocytes, involution changes and fibrosis. However, these changes may be subtle in patients who have been treated with long term high dose steroids, but helpful in establishing either AIT 1 or 2. Case A 56-year-old man with a history of cardiomyopathy with an ejection fraction of 30% and atrial flutter treated previously with six months of amiodarone, presented for a routine appointment found to be in atrial flutter with rapid ventricular rate. The patient was off amiodarone therapy for ∼ 6 months prior to current presentation. The patient was referred to the ER where initial vital signs were remarkable for heart rate in the 140s. Exam was remarkable for mild tremor of the outstretched bilateral hands. Labs were remarkable for TSH of 0.01 ulU/ml (0.27-4.20), Free T4 of 2.2 ng/dl (0.93-1.70), Free T3 of 5.9 pg/ml(2.3-4.2). Thyroid ultrasonography revealed a heterogeneously enlarged thyroid gland with no increased vascularity, and 2.4 cm isthmus nodule of a TI-RAD-3. Thyroid stimulating immunoglobulins (TSI) of 96 (<140%), and thyroid peroxidase (TPO) of 2IU/ml (<9). Thyroid radioactive iodine uptake (RAIU) revealed a severely decreased uptake in the setting of amiodarone use. Mixed AIT was suspected and patient was placed on titrated dose of Methimazole (MMI) and Prednisone. Approximately three weeks later, patient was discharged on MMI 40 mg TID and Prednisone 60 mg daily. He had a close outpatient follow up with further titration of prednisone to 80 mg daily. Due to prolonged nature of disease, he was subsequently referred for total thyroidectomy. Histological examination revealed subtle changes including desquamated follicular epithelial cells and intrafollicular foamy macrophages. The thyroid architecture was maintained and no inflammatory infiltrates of fibrosis were noted. These findings are consistent with AIT type 2. Conclusion AIT is a challenging diagnosis, and in medically refractory cases, total thyroidectomy is a curative option. The pathological findings in a patients treated with prolonged steroids may dampen inflammation of AIT2, and therefore careful histologic examination and monitoring of inflammatory markers may help to consolidate diagnosis. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT360 Thyrotoxicosis as a Delayed Response to Amiodarone

Abstract Introduction Amiodarone is often used in the treatment of cardiac dysrhythmia, but has been associated with toxicity of multiple organ systems including the thyroid. Patients treated with amiodarone can develop hypothyroidism or hyperthyroidism, also known as amiodarone induced thyrotoxicosis (AIT). AIT is further categorized into type I or type II depending on pathogenesis of the disease: type I resulting from increased hormone synthesis and type II resulting from glandular destruction. We report a case of a 68-year-old male patient who developed type II AIT approximately four years after cessation of Amiodarone therapy. Case Presentation A 64-year-old man initially presented to an outpatient endocrinology clinic for evaluation of incidental thyroid nodules. He had a normal thyroid function. His significant past medical history included atrial fibrillation/atrial flutter status post ablation. Thyroid ultrasound revealed bilateral subcentimeter nodules which remained stable over the subsequent two years. Approximately four years after establishing care, he presented to the endocrinologist again with weakness, decreased appetite, fatigue, and weight loss. Thyroid function testing revealed new onset hyperthyroidism with suppressed TSH, <0.01 mU/L (normal 0.5-5.0 mU/L), elevated FT4 4.5 ng/dL (normal 0.7-1.9 ng/dL) and elevated FT3, 7.4 pg/mL (normal 2.3-4.1 pg/mL). He had normal TSI, normal ESR, and no history of recent viral infection. Thyroid ultrasound showed stable subcentimetric nodules. Evaluation with radioactive iodine uptake (RAIU) scan was not possible due to recent contrast exposure during CT spine imaging. The patient was started on methimazole therapy with an assumptive diagnosis of toxic multinodular goiter. The dose was rapidly increased, within weeks, to 60mg daily, due to persistent severe hyperthyroidism. He was hospitalized twice for exacerbation of atrial fibrillation with rapid ventricular rate requiring cardioversion and augmentation of medical therapy. Further investigation revealed the patient had received amiodarone therapy for approximately three months, almost four years prior to his current presentation. A trial of 40mg prednisone daily was started in conjunction with methimazole for possible delayed type II AIT, resulting in a rapid improvement of symptoms and Free T4 levels. Once the patient's urinary iodine levels returned to normal, he underwent RAIU scan which revealed low uptake supporting the diagnosis of type II AIT. Methimazole therapy was stopped, and prednisone therapy was tapered down slowly and then discontinued over the course of three months, with complete resolution of hyperthyroidism. Conclusion This report reiterates the difficulties clinicians are often faced with when diagnosing and treating AIT, which, in our case, occurred four years after the discontinuation of amiodarone therapy. It highlights the importance of obtaining a history of remote amiodarone therapy, and considering steroids treatment for type II AIT, especially in patients with no clear other etiology and no response to high dose methimazole. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

The characteristics of pre-excitation syndrome concomitant with atrial tachyarrhythmia and the effect of radiofrequency ablation.

Wolff-Parkinson-White (WPW) concomitant with atrial tachyarrhythmia (ATA) has not been systemically characterized. Detailed electroanatomical mapping of the right atrium (RA) and/or left atrium (LA) was performed using three-dimensional mapping and the accessory pathway (AP) was mapped. WPW syndrome with ATA was diagnosed in 11 patients (median age 60 years). The characteristic of unidirectional anterograde conduction over the AP was displayed in nine patients, six of whom were intermittent. Sustained atrial tachycardia, that is, counterclockwise atrial flutter (AFL) with a median tachycardia cycle length (TCL) of 225 (220-275) ms, was mapped in eight patients; furthermore, "figure 8" right atrial reentry was mapped with TCL 250ms in one patient with a surgical history of ventricular septal defect repair. The remaining two patients underwent mitral annulus-dependent AT after paroxysmal atrial fibrillation (PAF) ablation and LA micro-reentry AT, respectively. In four patients, the location of the APs was left posterior. Left-lateral APs were identified in four patients. The locations of the APs in the remaining three patients were the right posterior and middle septum. All ATAs and APs were successfully ablated. After a median follow-up of 37 (15-72) months, no anterograde conduction over the AP was recorded, new onset of PAF was recorded in three patients, and all of them underwent circumferential pulmonary vein isolation. WPW with concomitant ATA frequently had continuous anterograde conduction over the AP with a rapid ventricular rate. Most WPWs displayed the characteristic of unidirectional anterograde conduction.

Clinical Case 10—An unusual case of thrombocytopenia following transfemoral aortic valve implantation

Abstract Clinical Case: An 85-year-old female patient with diabetes, hypertension, obesity, chronic kidney disease and severe aortic stenosis was submitted to transcatheter aortic valve implantation (TAVI). During procedure unfractionated heparin was administered. Intervention was performed without complications and she was discharged with platelet count of 116,000/μL. Fifteen days after (day 0), she was readmitted with dyspnea. Arterial blood gas showed hypoxemia and lactate levels of 5,8mmol/L. The ECG showed new-onset atrial fibrillation (AFib) with a rapid ventricular rate. Blood tests showed platelet count of 45,000/μL, D-dimers 2790ng/mL, worsening kidney function and high inflammation markers. An echocardiogram showed normofunctioning transcatheter aortic valve. Pulmonary embolism (PE) or respiratory infection with new-onset AFib were admitted. The patient started enoxaparin and an antibiotic. On day 4 the patient was oliguric needing dialysis. A CT Angiography was performed that excluded PE but showed several thrombus on the right atrium and appendix, right ventricle and on the abdominal aorta. Blood results showed hemolytic anemia. On day 8, the platelet count reached the nadir of 11 000/μL. At that time, differential diagnoses included thrombotic thrombocytopenic purpura (TTP), heparin-induced thrombocytopenia and sepsis-induced disseminated intravascular coagulation (DIC). Laboratory evaluation showed a near-normal coagulation profile and a PF4+ antibody. Enoxaparin was stopped; fondaparinux and plasma therapy were started. Platelet count took weeks to reach previous levels. The patient was discharged with a DOAC. It is usual to have some degree of thrombocytopenia after TAVI. In this case we have a complex and challenging scenario, properly handled, and with a good outcome.

Prognostic Impact of Landiolol in Patients with Acute Heart Failure and Atrial Fibrillation with Rapid Ventricular Rates: A Pilot Observational Study

Introduction: Guidelines recommend ventricular rate control to <130 bpm during atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) to avoid aggravating deteriorations in cardiac outputs. We aimed to evaluate the prognostic impact of landiolol in patients with ADHF and AF. Methods: This observational study included 60 patients who were urgently hospitalized with ADHF and presented with AF and a heart rate (HR) ≥130 bpm at admission. The patients were assigned to the landiolol group (n = 37) or the reference group (n = 23) based on their intravenous landiolol use within 24 h after admission. The primary endpoint was death from any cause. Results: The groups’ baseline characteristics were similar. A significant HR reduction occurred in the landiolol group at 2 h after admission. Compared with the reference group, the HR was significantly lower (111.6 vs. 97.9 bpm, p = 0.02) and the absolute HR reduction was greater (−32.2 vs. −50.0 bpm, p = 0.006) in the landiolol group at 48 h after admission. The landiolol group’s mortality rate was significantly lower than that in the reference group (log-rank test, p = 0.032). landiolol use within 24 h after admission was independently associated with lower all-cause mortality (adjusted hazard ratio: 0.15, 95% confidence interval: 0.02–0.92). Conclusion: Patients with ADHF and AF who received landiolol for rate control during the acute phase had better prognoses than those who did not receive landiolol.

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

UNTREATED PULMONARY ARTERIOVENOUS MALFORMATIONS IN A CARDIORESPIRATORY STORM

UNTREATED PULMONARY ARTERIOVENOUS MALFORMATIONS IN A CARDIORESPIRATORY STORM

S2384 The First Case of Water Immersion Endoscopy in the Definitive Diagnosis of Atrio: Esophageal Fistula

Introduction: Atrial fibrillation (AF) is the most common heart rhythm disorder with estimated global prevalence of 33.5 million. Catheter ablation is the treatment modality of choice for refractory AF. Atrio-esophageal fistula (AEF) is a serious complication of catheter ablation. Diagnosis is critical to the management of AEF, and includes computed tomography of the chest, esophagram and esophagogastroduodenoscopy (EGD). Prompt diagnosis of AEF is essential for survival. Case Description/Methods: A 56-year-old male with AF presented with fever, fatigue and bilateral leg weakness. Twenty days prior to presentation he underwent pulmonary vein isolation radiofrequency ablation and discharged the following day. Upon re-presentation his vitals were notable for fever and tachycardia. Labs revealed a normal white count and hemoglobin, and elevated lactate and troponin. One hour after arrival he developed complex focal seizure and AF with rapid ventricular rate followed by respiratory decompensation requiring intubation. His blood cultures revealed Streptococcus mitis and Gemella haemolysans. His MRI disclosed numerous bilateral emboli concerning for endocarditis, however TEE did not reveal any valvular vegetation, thus proposing AEF as a possible complication accounting for the emboli. CT chest angiogram revealed subtle irregularity along the posterior wall of the left atrium (figure A), but did not provide conclusive evidence to warrant high-risk cardiothoracic surgery. Water immersion EGD was performed to diagnose and localize the fistula, revealing esophageal defect in the proximal esophagus with movement of non-bloody debris through the tract (figure B). One hemostatic clip was placed near the tract to assist with localization for surgical closure. The following day the patient underwent right thoracotomy with placement of intercostal muscle flap to fistula (Figure C). Discussion: AEF is a rare complication of radiofrequency ablation therapy for AF. High mortality rate is primarily attributed to major cerebrovascular morbidity from septic thrombi. Currently there is no effective modality to visualize AEF safely and reliably. Water immersion colonoscopy allows for completion of difficult colonoscopies, decreased insertion pain, and increased adenoma-detection rates. This technique was applied to identify the AEF. Water immersion EGD is an important modality that can confidently be considered within the diagnostic armamentarium of gastroenterologists to ensure safe and rapid diagnosis and treatment of AEF.Figure 1.: 1: (A) Illustrates a subtle contour abnormality involving the posterior wall of the left atrium (arrow) concerning for AEF (B) Water immersion endoscopy illustrating 3mm defect (arrow) in the wall of the esophagus (C) Underwent right thoracotomy to access AEF. This image highlights 3mm fistula site (arrow) that is approximated to be at the midpoint of the atrium.

A TALE OF TWO THROMBI

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Atrial Fibrillation is associated with an increased risk of stroke secondary to left atrial thromboembolism. Its association with venous thromboembolism from the right atria is not well established (1). We report a rare case of a patient with atrial fibrillation (AF) with concomitant pulmonary embolism (PE) and left atrial appendage (LAA) thrombus. CASE PRESENTATION: The patient is a 61-year-old female with a remote history of provoked venous thromboembolism (VTE) and essential tremor who presented with progressively worsening dyspnea and fatigue. Her blood pressure was 121/78 mm Hg, pulse was 155 beats/min, respiratory rate was 18 breaths/min, and oxygen saturation was 93% on room air. EKG showed new atrial fibrillation with a rapid ventricular rate of 130-150 beats/min. A computed tomographic scan per pulmonary embolism protocol showed multiple acute emboli within the right middle and lower lobe. RV/LV ratio was 1.0. Troponin 0.05 ng/ml and BNP was 462 pg/ml. Transthoracic echocardiogram found EF 50-55%, normal right ventricular systolic function, no wall motion abnormalities. Bilateral lower extremity dopplers were negative for DVT. The patient was started on a diltiazem drip, however, continued to remain in RVR after 48 hours. Cardioversion was planned with a transesophageal echocardiogram (TEE) however, TEE showed left atrial appendage thrombus suggestive of prolonged duration of atrial fibrillation. An agitated saline study was negative for patent foramen ovale. During her prolonged hospitalization patient was started on metoprolol and digoxin after which rate control was achieved. The patient was discharged home on anticoagulation with a plan for atrial fibrillation ablation after resolution of thrombus. DISCUSSION: The patient was found to have acute PE without any provoking cause. This could have contributed to the development of atrial fibrillation. The TEE findings including bilateral atrial enlargement and left atrial appendage thrombus suggest a longer duration of uncontrolled atrial fibrillation prior to admission, especially considering the agitated saline study was negative for an intra-atrial shunt. In essence, she had both pulmonary arterial and venous thrombus simultaneously. CONCLUSIONS: Our report suggests that management of atrial fibrillation in the setting of LAA thrombus and PE can be challenging and may require multiple AV nodal blocking agents. The significance of venous and arterial thrombi in atrial fibrillation remains unclear. Studies are needed to assess the safety and efficacy of thrombolytics and long-term outcomes in these patients. Reference #1: Friberg L, Svennberg E. A diagnosis of atrial fibrillation is not a predictor for pulmonary embolism. Thromb Res. 2020 Nov;195:238-242. doi: 10.1016/j.thromres.2020.08.019. Epub 2020 Aug 10. PMID: 32799131. DISCLOSURES: No relevant relationships by Mukul Bhattarai No relevant relationships by radhika deshpande No relevant relationships by Abhishek Kalidas Kulkarni No relevant relationships by Raj Patel No relevant relationships by Prashanth Singanallur

Tachycardiomyopathy entails a dysfunctional pattern of interrelated mitochondrial functions

Tachycardiomyopathy is characterised by reversible left ventricular dysfunction, provoked by rapid ventricular rate. While the knowledge of mitochondria advanced in most cardiomyopathies, mitochondrial functions await elucidation in tachycardiomyopathy. Pacemakers were implanted in 61 rabbits. Tachypacing was performed with 330 bpm for 10 days (n = 11, early left ventricular dysfunction) or with up to 380 bpm over 30 days (n = 24, tachycardiomyopathy, TCM). In n = 26, pacemakers remained inactive (SHAM). Left ventricular tissue was subjected to respirometry, metabolomics and acetylomics. Results were assessed for translational relevance using a human-based model: induced pluripotent stem cell derived cardiomyocytes underwent field stimulation for 7 days (TACH–iPSC–CM). TCM animals showed systolic dysfunction compared to SHAM (fractional shortening 37.8 ± 1.0% vs. 21.9 ± 1.2%, SHAM vs. TCM, p < 0.0001). Histology revealed cardiomyocyte hypertrophy (cross-sectional area 393.2 ± 14.5 µm2 vs. 538.9 ± 23.8 µm2, p < 0.001) without fibrosis. Mitochondria were shifted to the intercalated discs and enlarged. Mitochondrial membrane potential remained stable in TCM. The metabolite profiles of ELVD and TCM were characterised by profound depletion of tricarboxylic acid cycle intermediates. Redox balance was shifted towards a more oxidised state (ratio of reduced to oxidised nicotinamide adenine dinucleotide 10.5 ± 2.1 vs. 4.0 ± 0.8, p < 0.01). The mitochondrial acetylome remained largely unchanged. Neither TCM nor TACH–iPSC–CM showed relevantly increased levels of reactive oxygen species. Oxidative phosphorylation capacity of TCM decreased modestly in skinned fibres (168.9 ± 11.2 vs. 124.6 ± 11.45 pmol·O2·s−1·mg−1 tissue, p < 0.05), but it did not in isolated mitochondria. The pattern of mitochondrial dysfunctions detected in two models of tachycardiomyopathy diverges from previously published characteristic signs of other heart failure aetiologies.