Right heart failure in the setting of thyrotoxic valvulopathy: the pathophysiology of an often neglected diagnosis: a case report

Background

Hyperthyroidism has a significant, well-established impact on the cardiovascular system on both a molecular and circulatory level. The cardiac consequences of thyrotoxicosis are not uncommon, indicated by a 1.2% prevalence of this disorder in the United States. However, our case describes the less widely observed association between thyrotoxicosis and valvulopathy.

Case summary

A 69-year-old Hispanic male presented with a 3-week history of shortness of breath, intermittent chest pain, and lower extremity swelling. Transthoracic echocardiogram revealed a dilated left and right atrium with severe tricuspid regurgitation, moderate mitral regurgitation, malcoaptation of the tricuspid valve leaflets, and a myxomatous mitral valve. In addition, right ventricular systolic function was moderately reduced. A right and left heart catheterization was performed with findings of normal right heart pressures and normal coronary arteries, respectively. To further evaluate the aetiology of the patient’s heart failure, thyroid studies were sent, revealing a thyroid-stimulating hormone value of <0.010 uIU/mL and a free T4 of 1.96 ng/dL. A 4.9 cm lesion was seen on thyroid ultrasound. We concluded that the patient’s heart failure and notable valvular abnormalities were likely as a result of thyrotoxic heart disease. Furosemide and methimazole were initiated while inpatient, and the patient was discharged with close follow-up.

Discussion

We demonstrate a unique case of the possible hemodynamic and cellular effects of thyroid hormone on the development of primary and secondary valve dysfunction. This association is important for clinicians to be aware of, as treatment of its underlying aetiology can lead to improvement in a patient’s cardiac outcomes.

Electrophysiologic Management and Considerations for D-transposition of the Great Arteries After Atrial Baffle Repair

This unique case highlights the electrophysiologic management and risk assessment of sudden cardiac death in a 35-year-old woman with a history of D-transposition of the great arteries status post–Mustard atrial switch repair.

Left ventricular free wall rupture as a result of delayed presentation of an inferior ST-elevation myocardial infarction due to fear of COVID-19: case report

Background

Left ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR.

Case presentation

We present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table.

Conclusions

The occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01495-x.

Distinguishing aortic valve thrombus from Libman-Sacks endocarditis in antiphospholipid syndrome: imaging and management

Aortic valve (AV) thrombus, a rare complication of antiphospholipid syndrome (APLS), is important to distinguish from Libman-Sacks endocarditis because of its responsiveness to anticoagulation. This may be attributed to immunopathologic differences underpinning their development. We present the case of a 45-year-old woman with high-risk primary APLS who developed an AV mass and was taken for valvular repair surgery but found to have pure thrombus and normal valve leaflets. In such cases, a trial of conservative management with anticoagulation may be adequate. Echocardiography, computed tomography and MRI findings suggestive of thrombus without endocarditis are presented. A literature review of histopathologic, imaging and treatment implications of pure AV thrombus in the context of APLS is included.

Epidemiology of Diabetes Mellitus and Cardiovascular Disease

PURPOSE OF REVIEW

Diabetes mellitus (DM) has become a rising epidemic in the last century, more pressing in the last few decades with the exponential rise of obesity, and has become one of the leading causes of death worldwide.

RECENT FINDINGS

Genetic variants have also been a new field of epidemiology research to determine the underlying genetic component of those risk factors and the association of DM with CVD. In light of its significant prevalence, patients remain unaware of their disease progression that arises from genetic and metabolic risk factors. As compared to non-diabetics, those with type 2 DM carry a higher mortality risk from cardiovascular disease (CVD) across different ethnicity groups and sex. The most common cardiovascular manifestations in those with DM include heart failure, peripheral arterial disease, and coronary heart disease. Although DM does predispose patients to CVD, it in fact is not a risk equivalent, but carries significant heterogeneity in risk for CVD.

Utility of cardiac MRI in determining percutaneous versus surgical post-infarction ventricular septal defect repair

AIM

Postmyocardial infarction ventricular septal defect (VSD) is a rare complication that can lead to rapid hemodynamic patient decompensation. The type of VSD repair relies on several factors including: size, location, timing and surgical expertise.

CASE

A 63-year-old man with a ST-elevation myocardial infarction underwent percutaneous coronary intervention of the right coronary artery. A holosystolic murmur was notable postcatheterization, and transthoracic echocardiogram confirmed a VSD. To characterize the VSD, a cardiac MRI demonstrated a large, serpiginous VSD and longitudinal septal tear. Given the anatomic complexity and stable hemodynamics, a surgical trans-left ventricular patch repair was performed.

CONCLUSION

We emphasize the importance of cardiac magnetic resonance as a decision-making tool, utilizing imaging to ascertain the anatomy combined with hemodynamics to determine optimal individualized therapy.

Disparity between angiographic coronary lesion complexity and lipid core plaques assessed by near-infrared spectroscopy

OBJECTIVE

The purpose of this study was to determine if there was a relationship between angiographic lesion complexity and the extent of lipid core plaque (LCP) identified by catheter-based near-infrared spectroscopy (NIRS).

BACKGROUND

The angiographic complexity of coronary artery disease (CAD) is used to predict outcomes in patients undergoing percutaneous coronary intervention (PCI). The SYNTAX score, an angiographic tool quantifying the complexity of CAD, is associated with PCI outcomes. Recently, a novel catheter-based imaging technique using NIRS can identify LCP, which also is associated with PCI periprocedural myocardial infarction (MI). However, it is unknown whether these events are related to distinct adverse event prone pathobiology, such as a LCP within a complex angiographic lesion. Thus, we hypothesized that LCP identified by NIRS would be associated with high SYNTAX score.

METHODS

Seventy-eight patients who underwent coronary angiography and target-vessel NIRS were selected from the Chemometric Observations of Lipid Core Containing Plaques of Interest in Native Coronary Arteries Registry, an industry sponsored registry to collate clinical findings in all patients undergoing NIRS evaluation. A lipid core burden index (LCBI) was obtained from the scan of the proximal 50 mm of the target vessel. Three vessel SYNTAX (total, tSYN) and target single vessel (only NIRS-interrogated vessel) SYNTAX (1vSYN) scores were calculated and compared to LCBI. High LCBI was defined as (>110) and was compared to tertile scores for 1vSYN score (low 0-5, intermediate 6-10, high ≥11) and previously established tertiles for tSYN score (low 0-22, intermediate 23-32, high ≥33).

RESULTS

Patients had mean age of 63 years with prevalence of females (10%), diabetes mellitus (28%), hypertension (88%), and smoking history (72%); 1vSYN and tSYN scores correlated poorly with LCBI [(r(2) = 0.25; P = 0.02; n = 78) and (r(2) = 0.24; P = 0.04; n = 78), respectively]. Mean LCBI did not differ significantly across all tertiles of 1vSYN or tSYN scores.

CONCLUSIONS

Angiographic SYNTAX score only weakly correlated with LCBI. It is of interest as well that high LCBI was also present in cases of low SYNTAX scores. The disparity between the degree of angiographic complexity and the amount of LCP supports postulated mechanisms of the adverse event propensity even in patients who demonstrate low angiographic complexity. Future studies are necessary to address the clinical significance of high LCBI in patients with low-to-intermediate angiographic complexity and their potential for PCI-related complications.

Comparison of demographic factors and cardiovascular risk factor control among U.S. adults with type 2 diabetes by insulin treatment classification

AIMS

Data on glucose and cardiovascular disease (CVD) risk factor control among persons with type 2 diabetes mellitus (DM) according to insulin treatment status are lacking. We examined DM control, risk factors, and comorbidities among U.S. persons according to insulin treatment status.

METHODS

In the U.S. National Health and Nutrition Examination Surveys 2003-2006, we examined in 10,637 adults aged ≥30 with type 2 DM the extent of control of A1c, LDL-C, HDL-C, triglycerides, and blood pressure (BP) and composite goal attainment by insulin use status.

RESULTS

6.6% (n=889, projected to 14.3 million) had type 2 DM; of these, 22.9% were insulin users and 57.2% were treated only by other diabetes medications. Overall, 58.2% had an A1c<7% (53 mmol/mol) (insulin users 33.1%, non-insulin treated 66.1%, and 77.9% of those not on medication, p<0.0001). Overall, 44.2% were at a BP goal of <130/80 mmHg, 43.8% had an LDL-C<100 mg/dl (2.6 mmol/L), and 13.9% a BMI<25 kg/m(2). Only 10.2% were simultaneously at A1c, LDL, and BP goals (5.4% of those on insulin).

CONCLUSIONS

U.S. adults with type 2 DM, especially those treated with insulin remain inadequately controlled for A1c and CVD risk factors and have a high prevalence of comorbidities.

Global cardiovascular disease risk assessment in United States adults with diabetes

BACKGROUND

Diabetes mellitus (DM) is often considered a risk equivalent for cardiovascular disease (CVD); however, the variation in CVD risk in adults with DM has not been described.

METHODS

We studied 1114 US adults aged ≥18 years with DM from national survey data and the proportion at low (<10%), intermediate (10-20%) and high (>20%) risk, or with CVD, by age, gender, ethnicity and diabetes type and treatment, and glycaemic and risk factor control by risk group.

RESULTS

Overall, 22.9% were low, 17.5% intermediate, 31.4% high risk and 28.2% had pre-existing CVD (total 59.6% high risk/CVD). More Hispanics (32.4%) and Blacks (30.6%) versus Whites (18.8%) were at lower risk (p<0.0001). Among type 1 versus 2 DM, 35% vs. 65% (p<0.0001) and among insulin users 68.1% were high risk or with CVD. However, among low-intermediate risk, >50% have metabolic syndrome and 7% chronic kidney disease, increasing the high risk/CVD group to 86.8%. Simultaneous achievement of HbA1c, blood pressure and low density lipoprotein-cholesterol goals was low (<15%) regardless of risk group.

CONCLUSIONS

Many DM patients are not at high 10-year CVD risk, but metabolic factors may place them at greater long-term risk. Risk assessment could help target the intensity of treatment.