Ahmed Rashed

Use of the Impella 2.5 left ventricular assist device in a patient with cardiogenic shock secondary to takotsubo cardiomyopathy

We report a case of cardiogenic shock, believed to be secondary to stress-induced cardiomyopathy, managed by an Impella 2.5 assist device. Apical ballooning pattern was evident on left ventriculogram with no significant coronary artery disease on coronary angiography. Cardiogenic shock was initially managed medically with inotropes and vasopressors, but because the patient was clinically deteriorating, an Impella 2.5 left ventricular assist device was implanted. Remarkable recovery occurred within 48 h of implantation with significant increase in ejection fraction and only minimal residual apical hypokinesis observed on repeat ventriculogram.

Bivalirudin versus heparin in women undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND The anticoagulant of choice during percutaneous coronary intervention (PCI) in women is not well established. METHODS An electronic search was conducted for trials that randomized patients undergoing PCI to bivalirudin versus heparin, and reported outcomes of interest in women. Random effects DerSimonian-Laird risk ratios (RR) were calculated. Main outcome was net adverse clinical events (NACE) at 30-days. Other outcomes included major adverse cardiac events (MACE), all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), and major bleeding at 30-days. 1-year all-cause mortality and MACE were also examined. RESULTS Nine trials that randomized women undergoing PCI to bivalirudin (n=3960) versus heparin (n=4050) were included. At 30-days, bivalirudin was associated with reduced risk of NACE (RR=0.85; 95% CI 0.73-0.98; p=0.03), mainly driven by reduction in major bleeding (RR=0.59; 95% CI 0.49-0.71; p<0.001) compared with heparin. No difference in MACE (p=0.92), all-cause mortality (p=0.23), MI (p=0.86); or TVR (p=0.53) was demonstrated between both groups. At 1-year, the risk of MACE and all-cause mortality was similar in both groups. On a subgroup analysis, the benefit associated with bivalirudin appeared to be less evident when Glycoprotein IIb/IIIa inhibitors (GPI) was used as bailout therapy with heparin, however without significant interaction. Furthermore, in STEMI population, no difference in NACE, MACE, or major bleeding was observed between both groups. CONCLUSION In women undergoing PCI, bivalirudin is associated with reduced risk of major bleeding and NACE compared with heparin especially when GPI is routinely used.

Reduced dose apixaban resolving dual cardiac chamber thrombi in a patient with ischaemic cardiomyopathy in sinus rhythm

Left atrial (LA) thrombus is a known sequela of atrial fibrillation (AF) but it is less frequently encountered in patients in sinus rhythm. Left ventricular (LV) dysfunction may predispose patients without evidence of atrial tachyarrhythmias to atrial thrombosis. Warfarin is the standard treatment for cardiac chamber thrombosis and prevention of the associated thromboembolic complications. Despite that apixaban was found to be superior to warfarin in prevention of stroke and systemic embolism in patients with AF, evidence for its use in treatment of cardiac chamber thrombi is scarce and is limited to case reports. We report a case of simultaneously occurring LV and LA thrombi successfully treated with reduced dose apixaban in a patient with ischaemic cardiomyopathy and in sinus rhythm. Although apixaban maybe a potential effective treatment for intracardiac thrombi, further studies are needed to demonstrate efficacy and safety of this agent in larger patient populations.

Myoepithelial carcinoma in the mediastinum involving the left atrium

We report a case of a 56-year-old male who presented with typical atrial flutter and was diagnosed with a large mediastinal mass, posterior to the ascending aorta, noted within the left atrium, compressing the superior vena cava and right superior pulmonary vein, and measuring >9.0 cm at its greatest diameter. Histopathological studies showed a myoepithelial carcinoma. The patient underwent tumor debulking and radiation therapy. This is the first report of a mediastinal myoepithelial carcinoma involving cardiac chambers.

Spontaneous Distal Right Coronary Artery Dissection in a Patient With Massive Pulmonary Embolism: Thrombolyze or Not?

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia, myocardial infarction, and sudden cardiac death. We report a case with SCAD of distal right coronary secondary to pulmonary thromboembolism. Reported treatment options for SCAD include medical therapy, thrombolysis, balloon angioplasty, and coronary artery bypass surgery. The decision as to which one depends on the clinical and angiographic factors. The benefit of thrombolysis in these patients is controversial. The prognosis in patients surviving the initial event is generally believed to be favorable. In patients who remain stable, conservative management seems to be safe and is compatible with a good long-term outcome.

Impella RP Support and Catheter-Directed Thrombolysis to Treat Right Ventricular Failure Caused by Pulmonary Embolism in 2 Patients

Right ventricular failure secondary to pulmonary embolism is associated with morbidity and death. The Impella RP System has often been used for percutaneous mechanical circulatory support in patients with right ventricular failure from other causes, including myocardial infarction, cardiac surgery, and left ventricular assist device implantation. We report 2 cases of massive pulmonary embolism in which combined Impella RP use and ultrasound-assisted catheter-directed thrombolysis effectively treated shock caused by right ventricular failure and contributed to successful outcomes. To our knowledge, only one other patient with this indication had been treated with the Impella RP device.

Sick Sinus Syndrome and Takotsubo Cardiomyopathy

Background. Takotsubo cardiomyopathy is associated with increased risk of ventricular arrhythmias, atrial fibrillation, and bradyarrhythmias. However, sinus node dysfunction is relatively infrequent in the setting of takotsubo cardiomyopathy. Case Report. We are reporting a case of a 73-year-old woman with a history of asymptomatic sinus bradycardia who developed sick sinus syndrome complicated by takotsubo cardiomyopathy. Conclusion. Acute symptomatic sick sinus syndrome in patients with preexisting silent sinus node dysfunction can trigger takotsubo cardiomyopathy. Understanding precipitating factors of takotsubo cardiomyopathy and identifying the patients at risk of life-threatening arrhythmia can help in refining risk stratification and therapy planning. Patients with sick sinus syndrome complicated by takotsubo cardiomyopathy may benefit from pacemaker implantation. However, evaluation on a case-by-case basis is mandatory.

Preliminary Report on the Safety and Efficacy of Staged versus Complete Revascularization in Patients with Multivessel Disease at the Time of Primary Percutaneous Coronary Intervention

Abstract This study aims to determine the safety and efficacy of complete versus staged‐percutaneous coronary intervention (PCI) of nonculprit lesions at the time of primary PCI in patients with multivessel disease. Recent trials had suggested that revascularization of nonculprit lesions at the time of primary PCI is associated with better outcomes, however; the optimum timing and overall safety of this approach is not well known. An observational prospective study was conducted, including 50 patients who presented with ST‐segment elevation myocardial infarction and found to have at least an additional nonculprit significant (> 70%) type A or B lesion. According to the operators discretion, patients either underwent complete revascularization of nonculprit significant lesions during primary PCI procedure or within 60 days of primary PCI (staged‐PCI). Safety outcomes evaluated were contrast‐induced nephropathy (CIN), the amount of contrast used, and fluoroscopy time. Efficacy outcome assessed was major adverse events (MACE) at 1 year. The fluoroscopy time and amount of contrast used were increased in complete revascularization group (35.3 ± 9.6 vs. 26.3 ± 6.7 minutes, p < 0.001, and 219.5 ± 35.1 vs. 187.5 ± 45.5 mL, p = 0.01, respectively); while incidence of CIN remained similar (p = 0.73). The incidence of MACE at 1 year was similar in both groups (23% in the complete revascularization group vs. 25% in the staged‐PCI group, p = 0.43). Complete revascularization and staged‐PCI of nonculprit type A or B lesions at the time of primary PCI were associated with similar long‐term outcomes and safety profile. Larger studies are needed to further validate these results.

AngioVac System Used for Vegetation Debulking in a Patient with Tricuspid Valve Endocarditis: A Case Report and Review of the Literature

AngioVac is a vacuum-based device approved in 2014 for percutaneous removal of undesirable materials from the intravascular system. Although numerous reports exist with regard to the use of the AngioVac device in aspiration of iliocaval, pulmonary, upper extremity, and right-sided heart chamber thrombi, very few data are present demonstrating its use in treatment of right-sided endocarditis. In this case report, we describe the novel device used in debulking a large right-sided tricuspid valve vegetation reducing the occurrence of septic embolisation and enhancing the efficacy of antibiotics in clearance of bloodstream infection. Further research is needed in larger RSIE patient populations to confirm the benefits and the potential of improved outcomes associated with the AngioVac device as well as identify its potential complications.

ST-SEGMENT ELEVATION ON DOBUTAMINE STRESS ECHOCARDIOGRAPHY: STEMI OR NOT?

Dobutamine stress echocardiography (DSE) is a useful diagnostic and prognostic tool in patients with known or suspected coronary artery disease (CAD). ST-segment elevation during recovery phase of DSE is a rare occurrence for patients with non obstructive CAD. A 57 year old male with a history of