The Role of Direct Oral Anticoagulants in the Treatment of Cancer-Associated Venous Thromboembolism: Review by Middle East and North African Experts

Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is based on careful balancing of the risks and benefits of available classes of treatment: vitamin K antagonists, low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs). Results from randomized controlled trials have shown the consistent efficacy of DOACs versus LMWH in the treatment of cancer-associated venous thromboembolism (VTE). However, increased major gastrointestinal bleeding was observed for edoxaban and rivaroxaban, but not apixaban, compared with LMWH dalteparin. Most guidelines recommend DOACs for the treatment of cancer-associated VTE in patients without gastrointestinal or genitourinary cancer, and with considerations for renal impairment and drug-drug interactions. These updates represent a major paradigm shift for clinicians in the Middle East and North Africa. The decision to prescribe a DOAC for a patient with cancer is not always straightforward, particularly in challenging subgroups of patients with an increased risk of bleeding. In patients with gastrointestinal malignancies who are at high risk of major gastrointestinal bleeds, apixaban may be the preferred DOAC; however, caution should be exercised if patients have upper or unresected lower gastrointestinal tumors. In patients with gastrointestinal malignancies and upper or unresected lower gastrointestinal tumors, LMWH may be preferred. Vitamin K antagonists should be used only when DOACs and LMWH are unavailable or unsuitable. In this review, we discuss the overall evidence for DOACs in the treatment of cancer-associated VTE and provide treatment suggestions for challenging subgroups of patients with cancer associated VTE.

Brucellosis complicated by piriformis myositis and sacroiliitis: A case report and a review of the literature

Brucellosis remains an endemic zoonosis in the Middle East, particularly in Lebanon, owing to the high consumption of raw meat and unpasteurized cheese. In this report, we present the case of a twenty-one-year-old girl who was diagnosed with brucellosis during the investigation of persistent fever and night sweats that was confirmed by an elevated Brucella agglutination titer at 1/160 for Brucella melitensis species, and an indirect Coombs at 1/1280. Unfortunately, owing to non-adherence to the antibiotic regimen prescribed, her condition progressed, resulting in piriformis myositis with sacroiliitis, an unusual complication of brucellosis. Resolution occurred following a treatment regimen comprising intravenous gentamycin 5mg/kg daily for two weeks along with rifampin 300mg TID, and doxycycline 100mg BID for 12 weeks. Furthermore, we conducted a literature review, which revealed the diagnostic and imaging criteria for this uncommon complication to be still unclear, as well as the lack of universally approved guidelines for its treatment. Brucella - myositis should be suspected when patients present with fever and back pain.

Kikuchi-Fujimoto disease associated with a flare-up of a leukocytoclastic vasculitis: A rare case report and review of literature

RATIONALE

Kikuchi-Fujimoto disease (KFD) also known as histiocytic necrotizing lymphadenopathy is an exceedingly rare cause of cervical lymphadenopathy, commonly accompanied by systemic symptoms such as fever, fatigue, night sweats, myalgia, skin rash.

PATIENT CONCERNS

In this paper, we report the case of a 22-year-old female patient who experienced a flare-up of leukocytoclastic vasculitis that was complicated by the appearance of a cervical lymph node with dysphagia, fever and nausea.

DIAGNOSIS

Infectious and autoimmune workup came back negative.

INTERVENTIONS

Excisional lymph node biopsy was done and the pathology results were consistent with histiocytic necrotizing lymphadenitis in keeping with Kikuchi-Fujimoto disease.

OUTCOMES

Patient improved on intravenous corticosteroids and was discharged on per os prednisone. Six month follow-up shows complete resolution of her symptoms.

LESSONS

KFD should be ruled out in patients with autoimmune or inflammatory diseases who develop lymphadenopathies.

Synthesis and preclinical evaluation of BOLD-100 radiolabeled with ruthenium-97 and ruthenium-103

BOLD-100 (formerly IT-139, KP1339), a well-established chemotherapeutic agent, is currently being investigated in clinical trials for the treatment of gastric, pancreatic, colorectal, and bile duct cancer. Despite numerous studies, the exact mode of action is still the subject of discussions. Radiolabeled BOLD-100 could be a powerful tool to clarify pharmacokinetic pathways of the compound and to predict therapy responses in patients using nuclear molecular imaging prior to the therapy. In this study, the radiosyntheses of carrier-added (c.a.) [97/103Ru]BOLD-100 were performed with the two ruthenium isotopes ruthenium-103 (103Ru; β-, γ) and ruthenium-97 (97Ru; EC, γ), of which in particular the latter isotope is suitable for imaging by single-photon emission computed tomography (SPECT). To identify the best tumor-to-background ratio for diagnostic imaging, biodistribution studies were performed with two different injected doses of c.a. [103Ru]BOLD-100 (3 and 30 mg kg-1) in Balb/c mice bearing CT26 allografts over a time period of 72 h. Additionally, ex vivo autoradiography of the tumors (24 h p.i.) was conducted. Our results indicate that the higher injected dose (30 mg kg-1) leads to more unspecific accumulation of the compound in non-targeted tissue, which is likely due to an overload of the albumin transport system. It was also shown that lower amounts of injected c.a. [103Ru]BOLD-100 resulted in a relatively higher tumor uptake and, therefore, a better tumor-to-background ratio, which are encouraging results for future imaging studies using c.a. [97Ru]BOLD-100.

Brucellosis Presenting as Isolated Abdominal Lymphadenopathy Masquerading as Lymphoma: A Case Report

Mesenteric lymphadenopathy associated with high-grade fever can be frequently associated with hematologic malignancies, especially if accompanied by joint pain, weight loss, and anorexia. However, this constellation of symptoms, also known as "B Symptoms," can be the uncommon presenting manifestation of brucellosis, still a common zoonotic disease in the Middle Eastern basin. In this article, we report the case of a Lebanese man who presented with "B symptoms" of three weeks duration, who was thought to have lymphoma but was later found to have systemic brucellosis.

A Case of Severe Proton Pump Inhibitor-Induced Hypomagnesemia Refractory to Continuous Oral and Intravenous Magnesium Replenishment

Proton pump inhibitors (PPIs) are frequently used medications to treat a wide variety of gastrointestinal conditions. By irreversibly inhibiting the hydrogen-potassium ATPase pump, they remarkably reduce gastric acid secretion. However, chronic PPI intake can result in serious complications, including severe hypomagnesemia. The following case report presents a severe case of refractory PPI-induced hypomagnesemia (PPIH), resistant to continuous oral and intravenous magnesium replacement, in a 70-year-old male patient, with a long history of PPI use due to persistent epigastric pain. Upon each of the 10 admissions to the hospital, he presented with severe signs and symptoms of hypomagnesemia, such as nausea, muscle fasciculation, diffuse cramps, weakness, neuromuscular irritability, and ECG disturbances, including non-specific T-wave abnormalities. In fact, PPIH has been reported for the first time in 2006. It is believed that the excessive, chronic intake of PPIs can disturb the normal functioning of the transient receptor potential melastatin 6/7 (TRPM 6/7), which is the main pathway of active intestinal magnesium absorption, leading to hypomagnesemia. PPIH is typically characterized by stubborn resistance to oral and intravenous magnesium replenishment but usually resolves after PPI withdrawal. Hence, despite being among the safest and most commonly prescribed drugs, PPI intake should be closely monitored when prolonged usage is planned. Additionally, continuous follow-up and regular assessment of serum magnesium levels are crucial to avoid the occurrence of PPIH and to prevent its potentially deleterious complications, including life-threatening arrhythmias.

Cognitive functions of patients treated with chemotherapy: A comparative study

OBJECTIVES

Chemobrain is a well-established clinical syndrome that has become an increasing concern because of the growing number of long-term cancer survivors. It refers to the post-chemotherapy related cognitive dysfunction. The aim of this study was to objectively assess the impact of cancer treatment on the cognition of cancer patients.

METHODS

This was a convenience sample comparative study conducted at the Hematology and Oncology Department of Hôtel Dieu de France University Hospital in Beirut, Lebanon. It included cancer patients (G1) aged under 65 years who had already been treated for cancer compared to two control groups. The first control group (G2) consisted of treatment-naïve cancer patients aged under 65, and the second group (G3) was recruited from a pool of healthy controls aged between 40 and 65 years. All participants were asked to complete the part B of the trail making test (TMT) and the digital symbolic substitution test (DSST).

RESULTS

In the bivariate analysis, patients in G1 had significantly higher scores than patients in G2 (P=0.017) and G3 (P<0.001) on the TMT-B. However, patients in G1 only had lower scores on DSST when compared with G3 (P=0.017). In the logistic regression taking different groups two-by-two as the dependent variable, the only significant difference was found in the comparison between G2 and G3 with higher TMT-B scores more in favor of belonging to G2 (OR=0.946; P=0.003).

CONCLUSIONS

Our results suggest that, after controlling for anxiety and depression symptoms, patients treated with chemotherapy have significantly poorer outcomes on the DSST and TMT-B than treatment-naïve cancer patients and healthy controls. However, when taking confounding factors into account, the difference only persisted between patients undergoing chemotherapy and healthy controls. These findings are in favor of a multifactor cognitive impairment in patients with cancer partially related to chemotherapeutic treatment.

The First Documented Ibuprofen-Induced Toxic Epidermal Necrolysis in the Middle East and North Africa Region: A Case Report, Complications, and Management

INTRODUCTION

Stevens-Johnson syndrome (SJS), Stevens-Johnson/toxic epidermal necrolysis overlap syndrome (SJS/TEN) and toxic epidermal necrolysis (TEN) are rare, acute, potentially lethal conditions, considered to be part of the severe cutaneous adverse reactions (SCARs) spectrum, with TEN being the most life-threatening. The distinction between these three entities is based on the extent of total skin surface involvement, with SJS involving < 10%, SJS/TEN involving 10-30% and TEN involving > 30% of total body surface area. These mucocutaneous reactions are most commonly caused by a hypersensitivity reaction to a drug, with infections and vaccines being possible, less common etiologies.

CASE PRESENTATION

In the following case report, we summarize a rare case of a 43-year-old, previously healthy male patient who presented with TEN after taking ibuprofen, a non-steroidal anti-inflammatory drug. According to PubMed literature, this is the first documented case of ibuprofen-induced TEN in the Middle East and North Africa (MENA) region.

DISCUSSION

TEN is an autoimmune bullous disorder that results in the death of keratinocytes, leading to complete dermo-epidermal separation. In the case of our patient, the desquamation was extensive, involving 70% of the total body surface area, and was complicated by a triple bacterial infection with Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient was treated with colistin and meropenem, in addition to supportive management, hydration and nutritional support.

CONCLUSION

In the case of TEN, early diagnosis and hospitalization in a burn centre are crucial to allow rapid healing, and improve the quality of life of the affected patients. Immediate cessation of the causative mediation is critical. Supportive management, hydration, nutritional support, and maintenance of aseptic conditions are highly encouraged to reduce the mortality and morbidity associated with TEN.

Social representations of intellectual disability; a comparison between cultures

OBJECTIVES

People with Intellectual disability consistently appear to be one of the most looked-down upon and repressed subgroups of society in many cultures. The main aim of this study was to compare social representations of intellectual disability in its various aspects between different cultures.

MATERIALS AND METHODS

The study was conducted in four different sites: Beirut-Lebanon, Algiers-Algeria, Tours-France and Namur-Belgium. Participants were asked to complete a questionnaire evaluating social representations of intellectual disability.

RESULTS

A total of 755 participants consented to take part in the study. Gender only affected social representations in the Lebanese population. Overall, Algerians appeared to have the least positive social representations and Lebanon to have more positive attitudes, while France and Belgium tended to have the most favourable representations.

DISCUSSION AND CONCLUSIONS

Findings highlight the imbalance between a European and a non-European country showing the importance of developing tailored interventions to improve general attitudes towards intellectual disability.

Lower limb amputation following venous cannulation for VA-ECMO: a case report

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

High fever in myelin oligodendrocyte glycoprotein-associated disorder (MOGAD): A diagnostic challenge

The phenotypic spectrum of myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorders (MOGAD) has broadened in the past few years, and atypical phenotypes are increasingly recognized. Febrile meningoencephalitis has rarely been reported as a feature of MOGAD and represents a diagnostic challenge. We report the case of 24-year-old women with high-grade fever, meningoencephalomyelitis, and persistently positive MOG-IgG, for whom an extensive infectious work-up was negative and who responded to high-dose intravenous methylprednisolone. The full clinical spectrum of MOGAD is yet to be completely elucidated. In patients presenting with febrile meningoencephalitis, MOG-IgG testing should be considered particularly if infectious work-up is negative.

EGFR Mutation in Non-squamous Non-small-cell Lung Carcinoma (NS-NSCLC) in the Arab World: A systematic Review

BACKGROUND

Lung cancer is the most frequent cause of cancer-related deaths worldwide. The discovery of acquired genetic alterations in the epidermal growth factor receptor (EGFR) gene involved in growth factor receptor signaling, has changed the way these cancers are diagnosed and treated. EGFR is more frequent in Asian, females, and non-smokers. Data regarding its prevalence in the Arab World remains limited. This paper aims at reviewing the data available for the prevalence of this mutation in the Arab patient population and comparing it with other international series.

METHODS

PubMed and ASCO databases were used to conduct a literature search and 18 relevant studies were included.

RESULTS

Overall, 1775 patients with non-small cell lung cancer (NSCLC) were included in this analysis. 15.7% had an EGFR mutation and 56% of the mutated patients were females. 66% of EGFR mutated patients were nonsmokers. Exon 19 and exon 21 were, respectively the most and the second most prevalent mutation.

CONCLUSIONS

The EGFR mutation frequency in Middle East and African patients lies between the frequency of Europe and North America. Like global data, it is more prevalent in females and non-smokers.

Echocardiographic diversity associated with exercise capacity in heart failure precursor stage B: the Project Baseline Health Study

Background

The current paradigm to stage heart failure (HF) defines precursor stage B (or “pre-HF”) as having any subclinical change in cardiac structure or function. Yet, HF risk factors and type of cardiac abnormality may induce clinically relevant heterogeneity in HF stage B. Therefore, we assessed clinical and echocardiographic heterogeneity within stage B HF and its association with exercise capacity in a large community-based sample.

Methods

2071 participants to the Baseline Health Study (50.4±17.0 years, 56.2% women, 37.8% hypertensive) underwent echocardiography and physical performance testing including 6-minute walk (6MWT) and treadmill exercise test. We defined echocardiographic profiles of left and right heart remodeling and dysfunction using sex-specific internal reference values. We assessed HF stages (0-A-B-C-D) following HF societies recommendations. stage B participants were stratified according to presence/absence of HF risk factors and to the most severe echocardiographic abnormality present (reduced ejection fraction (EF), left ventricular (LV) hypertrophy/diastolic dysfunction or other abnormalities). We reported associations between physical performance metrics and HF (sub)stages.

Results

Stage B HF was present in 516 participants (24.9%). Within stage B HF, we observed a large diversity in echocardiographic profiles. Yet, stage B participants without HF risk factors (n=96, 18.6% of stage B) predominantly presented echo abnormalities other than LV diastolic dysfunction, hypertrophy and reduced EF, while their physical performance profile resembled that of people with normal echocardiography without HF risk factors. In contrast, stage B participants with HF risk factors (n=420) were characterized by LV diastolic dysfunction, hypertrophy or reduced EF, three phenotypes associated with lower 6MWT distance and lower exercise capacity. Concomitant presence of HF risk factors and LV dysfunction/hypertrophy was associated with worst physical performance.

Conclusions

We observed a wide clinical and echocardiographic diversity affecting physical performance in HF precursor stage B when defined by the current staging paradigm. Concomitant presence of HF risk factors and LV dysfunction/hypertrophy may mark individuals at highest risk for progression towards overt HF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This research was made supported by an institutional research grant from Verily Inc. (CA, USA) and by the Research Foundation Flanders (Belgium).

Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience

BACKGROUND/PURPOSE

CoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks.

MATERIALS/METHODS

A retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done.

RESULTS

18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10-45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications.

CONCLUSIONS

Endovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.

Bulbar Symptoms as an Unusual Presentation of Multiple Sclerosis: A Case Report

Multiple sclerosis (MS) is a complex multifactorial disease with different clinical manifestations. Bulbar symptoms such as dysarthria and dysphagia are common in MS patients with advanced secondary progressive disease. However, they are not common at disease onset. We present the case of a 17-year-old male who initially presented with vomiting, dysarthria, and dysphagia. The investigations led to the diagnosis of MS, with an active lesion in the brainstem, more specifically in the area postrema region. Differential diagnoses were eliminated. The patient received intravenous methylprednisolone resulting in amelioration of symptoms. Treatment with fingolimod was started after discharge. The recognition of MS with atypical onsets is important to make an early accurate diagnosis and prescribe appropriate treatment for a disease known to be one of the most common causes of neurologic disability in young adults.

Presumed oculomotor nerve palsy following COVID-19 vaccination

We herein report the case of an 84-year-old female who presented to the outpatient clinic one day following her first dose of the Pfizer-BioNTech COVID-19 vaccine with mydriasis, ptosis, and a “down and out” gaze. She was subsequently diagnosed with oculomotor nerve palsy, and treated with corticosteroids and valacyclovir for a total of 7 days, with no clear improvement. On subsequent visits, ophthalmic examination improved steadily and showed complete resolution after 8 weeks. This article aims to report this unusual incidence that occurred following vaccination with the Pfizer-BioNTech COVID-19 vaccine. It is important for physicians to identify and report abnormal occurrences which may potentially be related to the COVID-19 vaccines, in order to reach a complete understanding of their possible side effects.

Thromboembolectomy for acute lower limb ischemia: Contemporary outcomes of two surgical methods from a single tertiary center

OBJECTIVES

The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE).

METHODS

This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis.

RESULTS

Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01).

CONCLUSION

ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Sclerostin and bone turnover markers response to cycling and running at the same moderate-to-vigorous exercise intensity in healthy men

BACKGROUND

Recreational cycling is a popular activity which stimulates and improves cardiovascular fitness. The corresponding benefits for bone are unclear.

PURPOSE

This study examined the effect of running (high-impact) vs. cycling (low-impact), at the same moderate-to-vigorous exercise intensity, on markers of bone formation (N-terminal propeptide of type I collagen, PINP) and bone resorption (C-telopeptide of type I collagen, CTX-1), a non-collagenous bone remodeling marker (osteocalcin), as well as bone-modulating factors, including parathyroid hormone (PTH), irisin (myokine) and sclerostin (osteokine).

METHODS

Thirteen healthy men (23.7 ± 1.0 y) performed two progressive exercise tests to exhaustion (peak VO₂) on a cycle ergometer (CE) and on a treadmill (TM). On subsequent separate days, in randomized order, participants performed 30-min continuous running or cycling at 70% heart rate reserve (HRR). Blood was drawn before, immediately post- and 1 h into recovery.

RESULTS

PTH transiently increased (CE, 51.7%; TM, 50.6%) immediately after exercise in both exercise modes. Sclerostin levels increased following running only (27.7%). Irisin increased following both running and cycling. In both exercise modes, CTX-1 decreased immediately after exercise, with no significant change in PINP and osteocalcin.

CONCLUSION

At the same moderate-to-vigorous exercise intensity, running appears to result in a greater transient sclerostin response compared with cycling, while the responses of bone markers, PTH and irisin are similar. The longer-term implications of this differential bone response need to be further examined.

Isolated Superior Mesenteric Artery Dissection: A Novel Etiology and a Review

Isolated superior mesenteric artery dissection (ISMAD) is a rare pathology with multifactorial etiology. The aim of this article is to provide a narrative review of the latest literature about ISMAD. Case reports, series, and recent meta-analyses were included. This review is introduced with a brief case report of a rare etiology of ISMAD, followed by a discussion of its etiology, clinical presentation, diagnosis, classification, and treatment, and we report a new cause of ISMAD, that is, blunt abdominal trauma. The etiology of ISMAD is multifactorial, consisting of anatomic, genetic, and systemic components. ISMAD is more common among middle-aged males and in East Asia. Its clinical presentation ranges from asymptomatic to mesenteric ischemia, albeit mortality remains <1%. It is diagnosed and classified mostly by computed tomography angiography, and there are five classification systems for ISMAD, though traumatic etiology may be added. The treatment of ISMAD is mostly conservative, with a success rate exceeding 90%. Endovascular stenting is second line, reserved so far for failed medical management, though its role is expanding to include earlier management of symptomatic patients, while open surgical repair is left for acute mesenteric ischemia with bowel compromise.

Proteomic profiling for detection of early-stage heart failure in the community

Background and purpose

Biomarkers may provide insight into the molecular mechanisms underlying cardiac remodelling and dysfunction. Using a targeted proteomic approach, we aimed to identify circulating biomarkers associated with early-stage heart failure and extract a proteome-based risk classifier for this condition.

Methods

575 community-based participants (mean age, 57 years; 51.7% women) underwent echocardiography and proteomic profiling (CVD II panel, Olink Proteomics). We applied partial least squares-discriminant analysis (PLS-DA) and a machine learning algorithm (extreme gradient boosting, XGBoost) to identify key proteins associated with echocardiographic abnormalities. We used Gaussian Mixture modelling for unbiased clustering to construct phenogroups based on influential proteins in PLS-DA and XGBoost.

Results

Of 87 proteins, 13 were important in PLS-DA and XGBoost modelling for detection of left ventricular (LV) remodelling, LV diastolic dysfunction and/or left atrial reservoir dysfunction: placenta growth factor, kidney injury molecule-1, prostasin, angiotensin-converting enzyme-2, galectin-9, cathepsin L1, matrix metalloproteinase-7, TNFR superfamily members 10A, 10B and 11A, interleukins-6 and 16 and alpha-1-microglobulin/bikunin precursor. Based on these proteins, the clustering algorithm divided the cohort into two distinct phenogroups, with each cluster grouping individuals with a similar protein profile. Participants belonging to the second cluster (n=118) were characterized by an unfavourable cardiovascular risk profile and adverse cardiac structure and function. The adjusted risk of presenting cardiac maladaptation was higher in this phenogroup than in the other cluster (P&lt;0.0001).

Conclusion

We identified proteins reflecting renal function, extracellular matrix remodelling, angiogenesis and inflammation to be associated with echocardiographic signs of early-stage heart failure. Focused proteomic phenomapping discriminated individuals at high risk for cardiac maladaptation in the community.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders

Temporal shift and accuracy of machine learning in heart transplant outcomes

Background

Accurate prediction of outcomes following a heart transplant is critical to explaining risks and benefits to patients and decision-making when considering potential organ offers. Given the large number of potential variables to be considered, this task may be most efficiently performed using machine learning (ML).

Purpose

We trained and tested different ML algorithms to accurately predict outcomes following a cardiac transplant using the United Network of Organ Sharing (UNOS) database.

Methods

We included 67 939 adult and pediatric patients enrolled in the UNOS database between January 1994 and December 2016 who underwent cardiac transplantation (median age 53 [IQR 38 – 60], 72.7% males). In our models, as an input, we included 114 features that have been collected from recipients and donors prior to transplant. The primary outcome was all-cause mortality at one-year post-transplant. We evaluated three different ML methods: XGBoost, Random Forest (RF) and L2 regularized logistic regression. Algorithms were trained and tested using shuffled 10-fold cross-validation (CV) as well as rolling CV. In the rolling CV, to mimic prospective procedure, ML models were trained by incrementally adding patients according to transplant year and testing models on the data in the following year. The hyperparameters, controlling the learning process, were tuned using Bayesian optimization. Prognostic accuracy for one-year all-cause mortality was characterized using the area under the receiver-operating characteristic curve (AUC).

Results

In total, 8,394 patients died within 1 year of transplant. We observed a substantial difference in prognostic accuracy between the shuffled 10-fold CV and the rolling CV. In the 10-fold CV, XGBoost and RF achieved high predictive performance with AUC of 0.848 (95% CI: 0.842–0.854) and 0.891 (95% CI: 0.886–0.896), respectively. In the rolling CV, which is a more realistic setting, AUC dropped to 0.673 (95% CI: 0.661–0.684) for XGBoost and 0.670 (0.657–0.683) for RF. Predictive performance of L2 regularized logistic regression remained stable across the two CV procedures, achieving AUC 0.669 (95% CI: 0.662–0.676) in the 10-fold shuffled CV and 0.665 (95% CI: 0.649–0.680) in the rolling CV procedure (Figure).

Conclusions

Our study suggests that ML models could be used to predict mortality in the first year post-transplant. We also show that the choice of CV procedure is crucial for evaluating ML models, particularly in data collected over a long period of time. The difference between the shuffled and rolling CV in the predictive performance of the tree-based ML models might indicate temporal dataset shift. In the rolling CV, all three methods achieved similar predictive performance.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders (FWO)

The association of soluble ACE2 change with metabolic health, body composition and proteome dynamics during a weight loss diet intervention: implications for the COVID-19 pandemic

Background

Angiotensin-converting enzyme 2 (ACE2) serves protective functions in metabolic, cardiovascular, renal and pulmonary diseases and is linked to COVID-19 pathology. We explored the association between soluble AC2 (sACE2) and metabolic health and proteome dynamics during a weight loss diet intervention.

Methods

We analyzed 457 healthy individuals (mean age 39.8±6.6) with BMI 28–40 kg/m2 who participated in the Diet Intervention Examining the Factors Interacting with Treatment Success (DIETFITS). Biochemical markers of metabolic health and 236 proteins measured by Olink CVD II, CVD III and Inflammation arrays were available at baseline and 6 months following dietary intervention. We determined clinical and routine biochemical correlates of the diet-induced change in sACE2 (ΔsACE2) using stepwise linear regression. We then combined feature selection models and multivariable-adjusted linear regression to identify protein dynamics associated with ΔsACE2.

Results

sACE2 decreased significantly on average at 6-months in the diet intervention. A stronger decline in sACE2 during the diet intervention was independently associated with female sex, lower HOMA-IR and LDL cholesterol at baseline, and a stronger decline in HOMA-IR, triglycerides, HDL-cholesterol and fat mass. In line, participants with decreasing HOMA-IR and triglycerides had significantly higher odds for a decrease in sACE2 during the diet intervention than those who did not (P≤0.0073 for both). Feature selection models linked ΔsACE2 to changes in AMBP, E-selectin, HAOX1, KIM-1, MERTK, PGF, thrombomodulin and TRAIL-R2. ΔsACE2 remained independently associated with these protein changes in multivariable-adjusted linear regression.

Conclusion

Decrease in sACE2 during a weight loss diet intervention was associated with improvements in metabolic health, fat mass and markers of angiotensin peptide metabolism, vascular injury, renal function, chronic inflammation and oxidative stress. Our findings may improve the risk stratification, prevention, and management of cardiometabolic and COVID-19-related complications.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIHResearch Foundation Flanders

Production of scandium radionuclides for theranostic applications: towards standardization of quality requirements

In the frame of "precision medicine", the scandium radionuclides have recently received considerable interest, providing personalised adjustment of radiation characteristics to optimize the efficiency of medical care or therapeutic benefit for particular groups of patients. Radionuclides of scandium, namely scandium-43 and scandium-44 (43/44Sc) as positron emitters and scandium-47 (47Sc), beta-radiation emitter, seem to fit ideally into the concept of theranostic pair. This paper aims to review the work on scandium isotopes production, coordination chemistry, radiolabeling, preclinical studies and the very first clinical studies. Finally, standardized procedures for scandium-based radiopharmaceuticals have been proposed as a basis to pave the way for elaboration of the Ph.Eur. monographs for perspective scandium radionuclides.

Assessing post-exercise respiratory gas kinetics in clinical sample - a pilot study

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiopulmonary exercise testing (CPX) is established in the evaluation of patients with cardiac and pulmonary diseases, and its clinical utility seems to be expanding.  Currently the most important diagnostic and prognostic ventilatory metrics of CPX rely on the exercise phase. Nevertheless, a consistent body of evidence suggests that important information can be derived from the recovery phase, especially in the first few minutes after exercise. In this context, patients with heart failure (HF) demonstrate a slower recovery of the oxygen consumption (VO2) compared with healthy individuals. Purpose: To comprehensively investigate the behavior of respiratory gases during recovery from CPX in a diverse cohort of HF patients. Methods: All individuals who performed CPX at the department of cardiology of Stanford University Hospital were eligible for the study. Patients were included in the experimental group if they (i) were recorded for five minutes after the exercise phase of CPX and (ii) had documented heart failure. They were excluded if they had other clinical diagnoses which may be responsible for exercise intolerance or symptoms or were unable to give informed consent. Healthy controls were recruited from the local community and were included if they did not have documented or suspected disease. Respiratory gases were collected on a breath-by-breath basis and analysed after applying a 30 second rolling average filter. Metrics were analyzed as absolute values, percentage change from peak and the half-time of recovery (T ½; i.e. the duration until a metric had returned to ½ of its value at peak). Data was analyzed over time within patients and averages between groups using parametric statistical methods. In accordance with previous studies, the amount of change in a metric after exercise is presented as the "magnitude" of overshoot. Results: 32 patients with HF (11 Female, 47 ± 13 yrs) and 30 healthy subjects (14 Female, 43 ± 12 yrs) were included. A comparison of ventilatory metrics during recovery between HF and controls is depicted in Figure 1. Peak VO2 was 1135 ± 419 mL/min (13.5 ± 3.8 mL/Kg/min) vs 2408 ± 787 mL/min (32.5 ± 9.0 mL/Kg/min); P &lt;0.01. A significant difference between patients with HF and healthy subjects was found in T ½ of VO2 (111.3 ± 51.0s vs 58.0 ± 13.2s, p &lt; 0.01) and VCO2 (132.0 ± 38.8s vs 74.3 ± 21.1s, p &lt; 0.01). The magnitude of the overshoot was also found to be significantly reduced in patients with HF for VE/VO2 (41.9 ± 29.1% vs 62.1 ± 17.7%, P &lt; 0.01), RQ (25.0 ± 13.6% vs 38.7 ± 15.1%, p &lt; 0.01) and PETO2 (7.2 ± 3.3% vs 10.1 ± 4.6%, p &lt; 0.01). Finally, the magnitude of the RQ overshoot showed a moderate correlation with peak VO2 (ϱ=0.58, p &lt; 0.01). Conclusions: We observed that ventilatory kinetics measured in early recovery after CPX differ significantly between healthy subjects and patients with HF. The assessment of post exercise respiratory gases in a clinical setting may add to the prognostic and diagnostic value of CPX in heart failure.

Abstract Figure.

Colorectal Metastasis from Ovarian Neoplasm Mimicking Primary Colon Cancer

Metastasis to the colon from another primary internal malignancy is an untypical and a seldom reported entity. Direct visualization during colonoscopy is considered the gold standard of diagnosis. Pathologic diagnosis with immunohistochemical staining is essential to differentiate primary colorectal malignancy from secondary metastasis to the colon. We, hereby, present a case of a 53-year-old female status-post resection of left-sided papillary serous ovarian neoplasm who presented 2 years later with a single rectosigmoid intraluminal ulcerative mass imitating a primary colon cancer. Biopsies of the mass were consistent with metastasis from her primary ovarian carcinoma. We believe this case is unique because of the rarity of ovarian cancer metastasizing to the colon intraluminally rather than through direct locoregional invasion. Furthermore, it highlights the importance of considering secondary metastasis in patients with previous history of another primary internal malignancy.

Challenges facing COVID-19 in rural areas: An experience from Lebanon

The COVID-19 pandemic first affected Lebanon on February 21st, 2020, and one month later it reached Bcharri, a small remote town in northern Lebanon. When similar rural areas with under-equipped facilities and financial limitations are affected, outcomes could be catastrophic, raising the need for meticulous preparation and rapid response. In our study, we describe the different measures taken to prepare this town for the COVID-19 outbreak, as well as our rapid response after the first case was confirmed. We emphasize the distinctions and the needs of rural areas when facing such threats, and the importance of a proactive community and local initiatives. We also detail our contact tracing strategy and massive testing campaign, as well as our early management of patients infected with COVID-19. We hope that our experience can be reproducible in areas with similar rural settings, during the COVID-19 pandemic and future outbreaks.

Microbiological profile and antimicrobial resistance among diabetic foot infections in Lebanon

Diabetic Foot Infection (DFI) is a challenging complication of diabetes mellitus with a high burden in the Middle East where there is a marked increase in diabetes prevalence and complications. Early detection of DFI and the infectious organisms could result in the early initiation of appropriate antibiotic therapy and improved outcomes. DFI microbiological profiles differ between countries. In our region, Western guidelines are used when initiating treatment for DFI in the absence of local guidance. The purpose of our study was to determine the microbiologic profile and antimicrobial susceptibility of the DFI admissions at a large tertiary referral centre in Beirut and review other reported series in Lebanon and our region. This is a retrospective observational study of patients with DFI admitted to the American University of Beirut Medical Centre from January 2008 to June 2017. The bacteriologic isolation and antimicrobial susceptibility tests were performed according to standard microbiological methods. Between 2008 and 2017, 319 diabetic patients with DFU were admitted to AUBMC, and deep-tissue cultures were taken for 179 patients. From 179 deep tissue cultures, 314 bacterial isolates were obtained. Fifty-four percent of patients had the polymicrobial infection. Aerobic gram-negative rods (GNR) were more prevalent than gram-positive cocci (GPC) (55%, 39%, respectively). The most common isolate was Escherichia coli (15%) followed by Enterococcus (14%) and Pseudomonas aeruginosa (11%). Staphylococcus aureus isolates accounted for 9% with 50% of them being methicillin-resistant (MRSA). Among Enterobacteriaceae, 37% of isolates were fluoroquinolone-resistant, 25% were ESBL producers, and 2% were carbapenem-resistant. Antibiotic resistance was significantly associated with prior usage of antibiotics. Anaerobes were isolated in 1% and Candida species in 5% of isolates. The sensitivity, specificity, PPV, and NPV of swab culture recovery of pathogens compared with deep tissue culture were (76%, 72%, 76%, 72%) and (94%, 81%, 91%, 86%) for gram-positive and gram-negative organisms, respectively. The microbiological profile of DFI in Lebanon is comparable to other countries in the MENA region with big differences compared with the West. Therefore, it is imperative to develop local guidelines for antimicrobial treatment. The high prevalence of GNR in DFI and the high fluoroquinolone resistance should be taken into consideration when choosing empiric antibiotics. Empiric treatment for MRSA or Pseudomonas does not appear necessary except for patients with specific risk factors.

Left atrial reservoir strain in relation to metabolic and inflammatory biomarkers: a community-based study

Background

The pathophysiological mechanisms that underlie progressive left atrium (LA) remodelling and dysfunction are only partially understood. Metabolic disturbances and chronic inflammation might mediate LA dysfunction. To date, population data investigating the contribution of these processes to LA reservoir dysfunction remain scarce.

Purpose

In a large population sample, we investigated the association between LA reservoir function and a panel of 38 metabolic and inflammatory biomarkers.

Methods

In 1236 community-dwelling individuals (mean age, 51.0 years; 51.5% women), we echocardiographically assessed LA reservoir strain (LARS) using 2D speckle-tracking analysis. LA reservoir dysfunction was defined as having LARS &lt;23%. We applied partial least squares-discriminant analysis (PLS-DA) to identify biomarkers associated with LA dysfunction. We further explored the associations between LARS and selected biomarkers that were the most influential in PLS-DA, while adjusting for important clinical correlates such as age, sex, body mass index (BMI), heart rate, systolic blood pressure (BP) and antihypertensive treatment. We applied stepwise regression to identify the clinical features and circulating biomarkers most valuable for prediction of abnormal LARS.

Results

The three latent factors constructed from the panel of 38 biomarkers during PLS-DA explained 16.9% of the variation between the normal and the impaired LA function group. The PLS-DA model discriminated between normal and abnormal LA reservoir strain with 79% accuracy (P&lt;0.0001). In PLS-DA, serum uric acid, serum insulin, γ-glutamyl transferase, interleukin-6, D-dimer and triglycerides were the top biomarkers responsible for class discrimination. On average, these top biomarkers were higher in the LA dysfunction group as compared to their normal counterparts (P&lt;0.0001 for all). In multivariable-adjusted continuous analyses, LARS decreased significantly with the level of serum insulin, serum uric acid and γ-glutamyl transferase (P≤0.0035 for all). Of the clinical correlates and the top biomarkers selected in PLS-DA, stepwise regression models highlighted age, BMI, systolic BP, serum insulin, serum uric acid and interleukin-6 as the main predictors of an impaired LA reservoir function (see figure). Conjointly, these clinical and biochemical features identified LA reservoir dysfunction with an overall accuracy of 85%.

Conclusions

Circulating markers of insulin resistance, hyperuricemia and chronic inflammation were independently associated with impaired LA reservoir function. These markers may help to further unravel the pathophysiological processes behind LA maladaptation and improve the management of early LA dysfunction in the community.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders

Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population

Background

Echocardiographic screening for subclinical left atrial (LA) dysfunction might enhance the prediction of cardiac diseases such as atrial fibrillation (AFib) in the community. To date, however, outcome-driven definitions of early-stage LA dysfunction remain scarce.

Purpose

In a large population sample, we sought to extract outcome-driven thresholds for echocardiographic indexes of LA function to define subclinical left atrial (LA) dysfunction and assess the prognostic value of these echocardiographic criteria for prediction of cardiac events.

Methods

In 1306 community-dwelling individuals (mean age, 50.7 years; 51.6% women), we assessed LA function and left ventricular (LV) global longitudinal strain (LS) by echocardiography. Using receiver-operating curve threshold analysis, we derived outcome-driven cut-offs for LA emptying fraction (LAEF) and LA reservoir strain (LARS) that best balanced the cardiac event prediction (i.e. cut-offs yielding the highest Youden index (=sensitivity+specificity-1)). Next, we constructed LA dysfunction profiles and integrative LA/LV strain profiles based on the extracted cut-offs for LAEF and LARS and a validated definition of impaired LV global LS. We assessed the prognostic performance of these profiles in predicting the incidence of cardiac events and AFib (mean follow-up, 8.5 years).

Results

During follow-up, 93 participants experienced a cardiac event (8.3 events/1000 person-years) and 27 developed AFib (2.3 events/1000 person-years). LAEF&lt;55% and LARS&lt;23% yielded the highest Youden indexes and thus provided the most balanced prediction of incident AFib. When applying these cut-offs, abnormal LAEF and LARS were respectively present in 27.0% and 18.1% of the cohort. Abnormal LARS was independently associated with higher risk for cardiac events (hazard ratio (HR) versus normal LA phenotype: 2.11, P=0.0021). Both abnormal LAEF (HR: 2.57) and abnormal LARS (HR: 3.28) predicted incident AFib (P≤0.029). As compared to subjects free from any LA dysfunction, those with both LAEF&lt;55% and LARS&lt;23% had a significantly higher risk to develop cardiac events (HR: 2.10; P=0.014) and AFib (HR: 6.45; P=0.0036). Of the integrative LA/LV strain profiles, the concomitant presence of an impaired LARS and LV global LS independently elevated the risk for cardiac events (HR: 2.81; P=0.0012) and AFib (HR: 4.36, P=0.0071) as compared to normal counterparts. Both the degree of LA dysfunction and the integrative LA/LV strain profiles improved the prognostic accuracy beyond clinical risk models and risk scores.

Conclusions

We validated population-based and outcome-driven definitions of subclinical LA dysfunction predicting cardiac events independent of conventional risk factors. Echocardiographic screening for subclinical LA and LV systolic dysfunction might enhance the prediction of cardiac diseases such as AFib in the community, empowering clinicians to timely intervene with the disease development.

Prediction of cardiac events

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders, Internal Funds KU Leuven

COVID-19 in a Patient Treated for Granulomatosis with Polyangiitis: Persistent Viral Shedding with No Cytokine Storm

Introduction

The coronavirus disease COVID-19 is considered a pandemic disease that has developed rapidly all over the world. As of today, it is unclear whether immunosuppression confers an increased risk for pulmonary complications, or conversely, whether it can be a protective factor with respect to a cytokine storm.

Case description

We report the case of a 55-year-old male patient with granulomatosis with polyangiitis treated with rituximab who was infected with COVID-19 pneumonia. To the best of our knowledge, only 1 case has been reported in the literature with similar characteristics. The patient had a non-classic evolution of clinical symptoms with persistent fever and viral shedding, in addition to a negative serology.

Conclusion

This case emphasizes the management and immunity response to COVID-19 pneumonia in such patients. Data are still needed regarding patients who have prolonged B-cell depletion, which may put the patient at a higher risk for reinfection.

LEARNING POINTS

Demonstration of the immunity response to COVID-19 pneumonia in an immunosuppressed patient.To highlight the management and evolution of such rare cases during this pandemic.

[Smoking cessation support workshops in medical training programs in Lebanon]

INTRODUCTION

Tobacco use is a major public health problem in our societies today. Nevertheless, effective smoking cessation interventions can reduce tobacco-related morbidity and mortality.

AIM

The aim of this study was to develop, implement, and evaluate a Competency-Based Approach (CBA) training program for residents in Lebanon aiming to improve their skills in counseling patients about smoking cessation.

METHODS

We followed a systematic educational planning starting by identification of professional tasks and competencies to acquire. A cross-sectional descriptive study was conducted for 16 residents to analyze learning needs and determine learning objectives. The workshop was chosen as a learning method. A pre-post intervention analysis made it possible to evaluate the progress.

RESULTS

Pre-intervention analysis showed that residents lacked skills and faced barriers in smoking cessation interventions (score of the items &#8220;General Knowledge&#8221;: 7.1/10; &#8220;Practices&#8221;: 6.5/10; &#8220;Skills&#8221;: 3.8/10; &#8220;Barriers&#8221;: 5.6/10). There were statistically significant improvements in all scores as well as significant decrease in barriers post-intervention (score of the items &#8220;General Knowledge&#8221;: 9.4/10; &#8220;Practices&#8221;: 9.2/10; &#8220;Skills&#8221;: 8.3/10; &#8220;Obstacles&#8221;: 2.1/10). The evaluation of the workshop was overwhelmingly positive.

CONCLUSION

A CBA workshop can improve residents&#8217; skills and effectiveness in counseling patients about smoking cessation. It should be integrated into the medical curriculum and delivered to every physician especially in a country with one of the highest rate of smoking and the weakest tobacco control strategies.

Management of Vascular Infections in Low- and Middle-Income Countries

Background: Vascular infections are rare and challenging conditions with significant deaths and morbidity. Their management necessitates a multi-disciplinary approach and substantial human and financial resources. The management selected may be influenced by the available resources in low- and middle-income countries (LMICs), where such resources may be variable. Methods: We reviewed the published literature and reviewed the management options for various vascular infections with a focus on carotid, aortic, infrainguinal, and dialysis access infections. Results: Recommendations related to prevention and treatment will be offered from the perspective of LMICs. The general principles for prevention are in compliance with established surgical site infection guidelines and minimize the use of prosthetic material. Early detection and intervention by removing all infected prosthetic material, debridement, drainage, and coverage of the infected field with vascularized tissue are essential steps in the management of the infection. Revascularization using an extra-anatomic or in situ approach is individualized based on the resources and expertise available. Conclusions: The prevention and management of vascular infections in LMICs are effective by adhering to time-proven principles even with limited resources.

Long-term results of endovenous laser ablation of saphenous vein reflux: Up to nine years of follow-up

INTRODUCTION

Endovenous laser ablation (EVLA) has become the gold standard for the treatment of saphenous vein reflux. We report the long-term clinical and ultrasound results of EVLA.

METHODS

This study is a retrospective review of patients who underwent EVLA of saphenous vein over four years. Clinical results were assessed using venous clinical severity score (VCSS), and ultrasound results were classified according to Bush classification.

RESULTS

Over a median follow-up time of 4.4 years, 168 EVLA-treated patients showed a drop in VCSS from 4.38 to 1.39. Ultrasound results of 140 treated great saphenous veins showed that 64% had one or more cause of recurrence. The presence of neovascularization correlated well with the lack of improvement of VCSS.

CONCLUSION

EVLA resulted in drop in VCSS from 4.38 to 1.39. Among 140 treated great saphenous veins, reflux in the anterior accessory saphenous vein was the primary cause (23.5%) of recurrence.

Vascular Complications in the Era of Transcatheter Treatment of Adult Structural Heart Disease: A Single-Center Early Experience

Transcatheter treatment is becoming the mainstay treatment for structural heart diseases (SHD) in prohibitive surgical risk patients. Recently with the encouraging results, it is being offered to regular risk patients. Peripheral vascular complications (VCs) are still inherent to these procedures due to the nature of this atherosclerotic high-risk group and the profile of the devices. This is a single-center early first year experience with such events occurring after initiating a SHD program treating severe aortic stenosis, aortic regurgitation, mitral valve prolapse and regurgitation, as well as paravalvular leaks. Out of 33 patients in this time period, 5 developed PV complications which are detailed in this article with their associated risk factors and management. These include access-related complications, closure device issues, arterial rupture post device embolization, and vessel dissection. Vascular complications of those procedures take special interest since they are associated with a worse long-term prognosis. Thus, prevention with proper planning remains of essence along with multidisciplinary management.