Sarju Ganatra

Intracranial hemorrhage in a patient with sub-massive pulmonary embolism treated with EkoSonic endovascular system directed thrombolysis: ICH With EkoSonic System Directed Thrombolysis

Ultrasound‐assisted catheter‐directed thrombolysis therapy has emerged more recently as a management strategy for patients with intermediate risk pulmonary embolism and has shown promising results in clinical trials by early reversal of right ventricle dilation, reduced pulmonary hypertension, and decreased anatomic thrombus burden. This therapeutic strategy requires a small fraction of the systemic fibrinolytic dose and is therefore associated with a reduced bleeding risk. Although intracranial hemorrhage has not been reported in clinical trials, it is a possible complication. Here we report the first case of intracranial hemorrhage related to the use of EkoSonic™ Endovascular System directed thrombolysis in a patient with large bilateral pulmonary embolism without any identifiable bleeding risks.

Immune Checkpoint Inhibitor‐Associated Myocarditis

Immune checkpoint inhibitors (ICIs) are approved for a wide range of malignancies. They work by priming the immune system response to cancer and have changed the landscape of available cancer treatments. As anticipated, modulation of the regulatory controls in the immune system with ICIs results in diverse immune-related adverse events, targeting any organ or gland. These toxicities are rarely fatal and generally regress after treatment discontinuation and/or prescription of corticosteroids. Recently, several cases of ICI-related cardiotoxicity have been reported with complications ranging from cardiogenic shock to sudden death. The true incidence of ICI-associated myocarditis is likely underestimated, due to a combination of factors including the lack of specificity in the clinical presentation, the potential of overlap with other cardiovascular and general medical illnesses, the challenges in the diagnosis, and a general lack of awareness of this condition. Currently, there are no clear guidelines for surveillance, diagnosis, or management of this entity. There are multiple unresolved issues including, but not limited to, identifying those at risk of this uncommon toxicity, elucidating the pathophysiology, determining if and what type of surveillance is appropriate, optimal work-up of suspected patients, and methods for resolution of myocarditis. Here we describe a clinical vignette and discuss the salient features and management strategies of ICI-associated myocarditis. KEY POINTS The incidence of immune checkpoint inhibitor (ICI)-associated myocarditis is unclear and has been reported to range from 0.06% to 1% of patients prescribed an ICI.Myocarditis may be difficult to diagnose.The risk factors for ICI-associated myocarditis are not well understood but may include underlying autoimmune disease and diabetes mellitus.The prevalence of myocarditis has been reported to be higher with combination immune therapies.Myocarditis with ICIs typically occurs early, with an elevated troponin, may present with an normal left ventricular ejection fraction and may have a fulminant course.The optimal management of myocarditis associated with ICIs is unclear but most cases are treated with high-dose steroids.

Cardio-Oncology for GenNext: A Missing Piece of the Training Puzzle

An aging population and an increase in cancer survivors has led to significant overlap between comorbid cardiovascular disease (CVD) and cancer [(1)][1]. Despite growing recognition of the importance and complexity of the relationship among cancer, its treatment, and CVD, the vast majority of

Ibrutinib-Associated Atrial Fibrillation

Ibrutinib, a novel and potent Bruton tyrosine kinase inhibitor, is an effective and well-tolerated treatment for a variety of B-cell lymphomas. However, its use is associated with an increased incidence of atrial fibrillation (AF), ranging from 4% to 16%. We reviewed the original clinical trials that led to the approval of ibrutinib, as well as several other prospective and retrospective studies, to better appreciate the incidence of ibrutinib-associated AF. Based on 16 studies included in our analysis, the incidence of ibrutinib-associated AF was 5.77 per 100 person-years, which is much higher than rates previously reported with ibrutinib and compared with the general adult population. New onset AF in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. In addition, ibrutinib poses unique challenges due to its interactions with many medications that are commonly used to manage AF. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation have to be carefully weighed against this increased risk of bleeding. Ibrutinibs interaction with calcium channel blockers, digoxin, amiodarone, and direct oral anticoagulants can result in either ibrutinib or other drug-related toxicity and careful selection and dose adjustment may be needed. Ibrutinib-associated AF can be a therapy-limiting side effect and physicians should be familiar with the special management considerations imposed by this agent. We review the potential mechanisms and incidence of ibrutinib-associated AF and propose an algorithm for its management.

Propafenone Induced 1:1 Atrial Flutter Conduction

A sixty-seven year old male with a past medical history of diabetes, hypertension, hypercholesterolemia, lung cancer in remission and COPD was diagnosed with symptomatic atrial fibrillation (AF) a month prior to his admission at our institution. He underwent external cardioversion at that time and started on beta blocker, but that had to be discontinued soon thereafter secondary to fatigue. Patient was then started on long acting Verapamil 120 mg daily and Propafenone 225 mg twice a day.

A rare form of imported infectious heart block

Background: Chagas disease is endemic in the southern cone of Latin America and is becoming more prevalent in the United States with more than 300,000 people infected. It is an important cause of heart block worldwide, but is thought to be rare in the United States, and therefore easily overlooked. Heart block from Chagas disease often occurs in the young, and is permanent; therefore, early diagnosis and treatment is crucial. Case report: A 37-year-old woman from Bolivia presented with decreased exercise capacity and generalized fatigue. Her electrocardiogram revealed right bundle branch block escape rhythm. Her enzyme-linked immunosorbent assay for Trypanosoma cruzi was negative, but given the high level of suspicion, an immunofluorescent antibody assay was performed, which was diagnostic. She was treated with benznidazole and permanent pacemaker placement. Conclusion: Chagas disease is becoming more prevalent in the United States and other regions of the developed world. Patients presenting from an endemic area with suggestive symptoms require investigation to detect this diagnosis because therapy restores patients to full functional capacity in the short term; in the long term, the prognosis is uncertain but cardiac surveillance for progressive ventricular dysfunction, thrombosis, and tachyarrhythmia is indicated. Treatment with anti-trypanosomal agents should be offered to patients with chronic Chagas disease and a permanent pacemaker should be considered in symptomatic patients with bradycardia.