Cardiac Tamponade With a Transaortic Percutaneous Left Ventricular Assist Device: When Alarms Caused No Alarm

A 57-year-old man with end-stage heart failure presented with incessant ventricular tachycardia in the setting of cardiogenic shock, requiring support with a percutaneous left ventricular assist device. He underwent ablation of the ventricular tachycardia. Hours later the console alarm was evident, and the patient experienced worsening shock and elevated central venous pressure, leading to a diagnosis of cardiac tamponade. (Level of Difficulty: Advanced.).

Endocarditis Presenting as Right Atrial Mass, Diagnosed with 18F-Fluorodeoxyglucose-PET: A Case Report

We report a case of a 55-year-old male with a history of methicillin-resistant staphylococcus aureus bacteremia whose initial transesophageal echocardiography revealed a cardiac mass attached to the right atrium. Because of the uncommon location of the mass, 18F-fluorodeoxyglucose-PET was used to confirm the diagnosis of infective endocarditis.

Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study

BACKGROUND

Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences.

METHODS

Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated.

RESULTS

Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033).

CONCLUSIONS

CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed.

TRIAL REGISTRATION

NA.

Case report of isolated cardiac sarcoidosis presenting as hypertrophic obstructive cardiomyopathy-a clinical picture printed on lenticular paper

Background

Cardiac sarcoidosis (CS) is an inflammatory granulomatous process of the myocardium that can be asymptomatic or have several different clinical phenotypes. One of its rarely described presentations consists of hypertrophy of the septal myocardium, similar to hypertrophic cardiomyopathy (HCM). Isolated cardiac sarcoidosis that haemodynamically mimics hypertrophic obstructive cardiomyopathy (HOCM) has been rarely described in the literature.

Case summary

A 64-year-old Caucasian female previously diagnosed with non-critical aortic stenosis presented with pre-syncope, and echocardiography showed significant obstruction based on left ventricular outflow tract gradients, confirmed by cardiac magnetic resonance (CMR), concerning for a phenocopy of HCM. Septal myectomy was performed and pathology specimen revealed non-caseating granulomata consistent with cardiac sarcoidosis. She was started on oral corticosteroids and initial cardiac fluorodeoxyglucose positron emission tomography (FDG-PET) done after 1 month of treatment was negative. Repeat FDG-PET 15 months later, in the setting of haemodynamic decompensation, demonstrated diffuse FDG uptake in the myocardium without extra-cardiac involvement.

Discussion

Our case brings together two entities: isolated cardiac sarcoidosis and its presentation mimicking HOCM, which has been very rarely described in the literature. And it also shows the scenario of surgical pathology diagnosis of sarcoidosis that was not suspected by initial CMR or FDG-PET, despite adequate preparation, only appearing on repeat FDG-PET done 15 months later. Isolated cardiac sarcoidosis should remain a differential diagnosis for any non-ischaemic cardiomyopathy without a clear cause, despite imaging evidence of HCM.

Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women

Background

The incidence of cardiovascular disease among pregnant women is rising in the United States. Data on racial disparities for the major cardiovascular events during pregnancy are limited.

Methods and Results

Pregnant and post‐partum women hospitalized from January 2007 to December 2017 were identified from the Nationwide Inpatient Sample. The outcomes of interest included: in‐hospital mortality, myocardial infarction, stroke, pulmonary embolism, and peripartum cardiomyopathy. Multivariate regression analysis was used to assess the independent association between race and in‐hospital outcomes. Among 46 700 637 pregnancy‐related hospitalizations, 21 663 575 (46.4%) were White, 6 302 089 (13.5%) were Black, and 8 914 065 (19.1%) were Hispanic. The trends of mortality and stroke declined significantly in Black women, but however, were mostly unchanged among White women. The incidence of mortality and cardiovascular morbidity was highest among Black women followed by White women, then Hispanic women. The majority of Blacks (62.3%) were insured by Medicaid while the majority of White patients had private insurance (61.9%). Most of Black women were below‐median income (71.2%) while over half of the White patients were above the median income (52.7%). Compared with White women, Black women had the highest mortality with adjusted odds ratio (aOR) of 1.45, 95% CI (1.21–1.73); myocardial infarction with aOR of 1.23, 95% CI (1.06–1.42); stroke with aOR of 1.57, 95% CI (1.41–1.74); pulmonary embolism with aOR of 1.42, 95% CI (1.30–1.56); and peripartum cardiomyopathy with aOR of 1.71, 95 % CI (1.66–1.76).

Conclusions

Significant racial disparities exist in major cardiovascular events among pregnant and post‐partum women. Further efforts are needed to minimize these differences.

Peroxisome Proliferator-Activated Receptor Gamma Coactivator-1 Alpha as a Novel Target for Bipolar Disorder and Other Neuropsychiatric Disorders

Peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1 alpha) is a protein that regulates metabolism and inflammation by activating nuclear receptors, especially the family of peroxisome proliferator-activated receptors (PPARs). PGC-1 alpha and PPARs also regulate mitochondrial biogenesis, cellular energy production, thermogenesis, and lipid metabolism. Brain energy metabolism may also be regulated in part by the interaction between PGC-1 alpha and PPARs. Because neurodegenerative diseases (Huntington's disease, Parkinson's disease, and amyotrophic lateral sclerosis) and bipolar disorder have been associated with dysregulated mitochondrial and brain energy metabolism, PGC-1 alpha may represent a potential drug target for these conditions. The purpose of this article is to review the physiology of PGC-1 alpha, PPARs, and the role of PPAR agonists to target PGC-1 alpha to treat neurodegenerative diseases and bipolar disorder. We also review clinical trials of repurposed antidiabetic thiazolidines and anti-triglyceride fibrates (PPAR agonists) for neurodegenerative diseases and bipolar disorder. PGC-1 alpha and PPARs are innovative potential targets for bipolar disorder and warrant future clinical trials.

Getting to wellness: The potential of the athletic model of marginal gains for the treatment of bipolar disorder

OBJECTIVE

People with bipolar disorder frequently have persistent symptoms, continued problems functioning and comorbid medical conditions. We propose applying the athletic coaching concept of marginal gains to help patients address these challenges to achieve wellness.

METHOD

We review the concept of marginal gains and potential interventions to improve long-term outcomes for bipolar patients.

RESULTS

Evidence exists to help bipolar patients with diet and exercise, gradual behavioral change, mobile applications and peer support.

CONCLUSION

Marginal gains, small and doable improvements across a broad range of areas, have great potential to improve the lives of people with bipolar disorder.