Ismayl, Mahmoud

Introduction and importance: Chest pain is one of the most prevalent complaints amongst individuals presenting in healthcare settings, encompassing a broad spectrum of etiologies. Work-up for chest pain often focuses on excluding life-threatening conditions before the consideration of atypical causes. Case presentation: A 47-year-old male with a past medical history of tobacco use and depression presented with persistent left-sided chest pain. Vitals on arrival were notable for mild hypertension. Two consecutive high-sensitivity troponins were unremarkable. The electrocardiogram showed sinus rhythm with no ischemic changes. Due to the atypical presentation of chest pain, the patient’s home medications were reviewed, and his bupropion was discontinued due to concern for medication-induced chest pain. The patient was discharged and presented 2 days for follow-up endorsing complete resolution of his chest pain. Clinical discussion: Prior investigations have shown bupropion to be associated with chest pain, with resolution noted after discontinuation. The etiology of chest pain is likely sympathomimetic, as bupropion has been shown to exhibit positive inotropic effects on myocardial tissue, propagated by catecholamine release. Conclusion: Patients taking bupropion may present with atypical chest pain. Medication discontinuation may be beneficial in alleviating symptoms.

Introduction and importance: Chest pain is a frequent reason patients seek medical attention. The broad spectrum of potential etiologies makes determining the underlying cause of chest pain complex. Among cardiovascular etiologies, aortitis is a rare but life-threatening possibility that should be considered in the differential diagnosis. Case presentation: A 53-year-old female with a history of smoking presented with progressively worsening chest and epigastric pain over several weeks. She had seen multiple physicians previously for the same symptoms with unremarkable work-ups. Physical examination was notable for severe tenderness upon palpation of her lower abdomen. The electrocardiogram and troponins were unremarkable. Computed tomography of the abdomen revealed aneurysmal dilatation of the abdominal aorta, soft tissue thickening, and surrounding inflammatory stranding, consistent with aortitis. Infectious and autoimmune work-ups were unremarkable. Intravenous steroids were initiated, and her symptoms improved significantly. Her aortitis was attributed to inflammation secondary to chronic smoking. Clinical discussion: Aortitis is a rare condition with varied clinical presentations. Etiologies of aortitis include infection and non-infectious inflammation. Diagnosis of aortitis requires a thorough clinical assessment and prompt imaging of the aorta, with computed tomography being the preferred imaging modality. Conclusion: Evaluation for cardiovascular chest pain must extend beyond an electrocardiogram and troponin level. Imaging should be considered in patients with atypical symptoms. Aortitis is a rare but important diagnosis requiring immediate treatment.

Introduction and importance: While vaping has increased significantly among young individuals, the effects of vape aerosol constituents on cardiac electrophysiological dynamics remain unknown. Case presentation: A 22-year-old female with a history of energy vaping presented with cardiac arrest. Found to have no pulse, CPR was started and an initial rhythm of ventricular tachycardia was obtained. Shock was administered with a follow-up rhythm of ventricular fibrillation. She was emergently defibrillated and entered atrial fibrillation with rapid ventricular response. Toxicology and troponins were all negative. Left heart catheterization and cardiac MRI were unremarkable. She was discharged with an external defibrillation vest and a tentative plan for outpatient electrophysiology study in the setting of negative work-up for cardiopulmonary arrest. Clinical discussion: Vaping-induced sudden cardiac arrest may be attributed to a reduction in cardiac repolarization reserve. Exposure to vegetable glycerin and propylene glycol, substances present in nearly all vape products, have been found to incite arrhythmias and disrupt cardiac conduction in animals. Acrolein, an aldehyde byproduct of glycerin, has also been found to induce arrhythmias due to autonomic dysfunction. Increased intracellular calcium concentration and free radical damage, which occur as a result of inhaling particulate matter generated from e-cigarettes, further propagates the risk of arrhythmia. Conclusion: The effects of inhaling vape aerosols remain not fully understood. While there is a perceived notion that nicotine-free aerosols may be harmless, that remains unclear. Further studies are needed to evaluate proarrhythmogenic effects and autonomic dysfunction from the various chemical substances present in vape aerosols.

Abstract Aims Data on safety outcomes of left atrial appendage occlusion (LAAO) in elderly patients are limited. This study aimed to compare the outcomes of LAAO between octogenarians (age 80–89) and nonagenarians (age ≥90) vs. younger patients (age ≤79). Methods and results We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients hospitalized for LAAO from 2016 to 2020 and to compare in-hospital safety outcomes in octogenarians and nonagenarians vs. younger patients. The primary outcome was a composite of in-hospital all-cause mortality or stroke. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. Outcomes were determined using logistic regression models. Among 84 140 patients hospitalized for LAAO, 32.9% were octogenarians, 2.8% were nonagenarians, and 64.3% were ≤79 years of age. Over the study period, the volume of LAAO increased in all age groups (all Ptrend < 0.01). After adjustment for clinical and demographic factors, octogenarians and nonagenarians had similar odds of in-hospital all-cause mortality or stroke [adjusted odds ratio (aOR) 1.41, 95% confidence interval (CI) 0.93–2.13 for octogenarians; aOR 1.69, 95% CI 0.67–3.92 for nonagenarians], cardiac tamponade, acute kidney injury, major bleeding, and blood transfusion, in addition to similar LOS and total costs compared with younger patients (all P > 0.05). However, octogenarians and nonagenarians had higher odds of vascular complications compared with younger patients (aOR 1.47, 95% CI 1.08–1.99 for octogenarians; aOR 1.60, 95% CI 1.18–2.97 for nonagenarians). Conclusion Octogenarians and nonagenarians undergoing LAAO have a similar safety profile compared with clinically similar younger patients except for higher odds of vascular complications.

Background: Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion. Case summary: A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient’s request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management. Discussion: Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke. Conclusion: Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.

Background: Clinical outcomes of catheter-based thrombectomy (CBT) compared with surgical embolectomy (SE) in patients with massive pulmonary embolism (mPE) have not been previously examined. Methods: We conducted a retrospective cohort study using the 2016-2020 National Inpatient Sample database to compare the outcomes of CBT versus SE in patients with mPE. Outcomes of interest included risk-adjusted in-hospital mortality, major bleeding, stroke, acute kidney injury (AKI), hospital length of stay (LOS), and total cost. Results: The total cohort included 5,845 patients with mPE, of which 5,490 (93.9%) underwent CBT and 215 (3.7%) underwent SE. After risk-adjustment, CBT had similar odds of in-hospital mortality (adjusted odds ratio [aOR] 1.49, 95% confidence interval [CI] 0.60-3.66, p=0.37) and stroke (aOR 1.49, 95% CI 0.30-7.38, p=0.62), lower odds of major bleeding (aOR 0.28, 95% CI 0.13-0.63, p<0.01), and higher odds of AKI (aOR 2.40, 95% CI 1.11-5.17, p=0.02) compared with SE. CBT had a similar LOS (p=0.58) and total cost (p=0.23) compared with SE. Between 2016 and 2020, there was a temporal increase in the performance of CBT in patients with mPE (p trend <0.01). Conclusions: In patients with massive PE, CBT was associated with similar in-hospital mortality, stroke, LOS, and total cost, lower major bleeding, and higher AKI compared with SE. Randomized controlled trials are indicated to confirm our findings.

Introduction and Importance: Current guidelines recommend against pre-procedural transesophageal echocardiogram (TEE) prior to cardioversion in atrial fibrillation patients compliant with oral anticoagulants for at least 3 weeks. The relevance of these guidelines remain unclear in those undergoing repeat cardioversion. Case Presentation: 66-year-old male with a history of atrial fibrillation and an implanted left atrial appendage occlusion device(LAAO), compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm 10 days prior to symptom onset with TEE unremarkable for thrombus. Vitals were remarkable for tachycardia and electrocardiogram revealed that the patient converted back into atrial fibrillation. Patient was then scheduled for cardioversion. At the patient’s request, a TEE was obtained which revealed a new thrombus in the left atrium located on his WATCHMAN device. Cardioversion was canceled and patient was admitted for coumadin initiation with lovenox bridge along with neurological monitoring due to increased stroke risk. Clinical Discussion: Restoration of sinus rhythm after cardioversion can lead to thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium.Atrial stunning occurs immediately after cardioversion and can persist for several weeks. Time-span of preceding atrial fibrillation, presence of structural cardiovascular disease, and atrial size impact severity of atrial stunning and duration of anticoagulation needed.While anticoagulation decreases the risk of thrombus formation, it does not completely eliminate it, especially in those with increased stroke risk factors. Conclusion: Atrial fibrillation patients are susceptible to thrombus formation after cardioversion.Further studies should be done to assess the need for routine TEE after cardioversion in those with increased risk for stroke on anticoagulants or who have LAAO.

Introduction and Importance: While the use of vaping has increased significantly among young individuals, the effects of the various vape aerosol chemical contents on cardiac electrophysiological dynamics remain unknown. Case Presentation: A 22-year-old female with a history of energy vaping but no significant past medical history presented with cardiac arrest. Found to have no pulse, CPR was started and initial rhythm of ventricular tachycardia was obtained. Shock was administered with follow-up rhythm of ventricular fibrillation. Patient was shocked again and entered atrial fibrillation with rapid ventricular response. She later cardioverted into sinus tachycardia and was intubated. Transthoracic echocardiogram showed normal ejection fraction but was otherwise unremarkable. Patient was extubated on day four of hospitalization. Left heart catheterization and cardiac MRI were completely unremarkable. Toxicology, urine analysis, and troponins were all negative. Patient was discharged with metoprolol tartrate, and a life-vest with outpatient follow-ups for possible implantable cardioverter-defibrillator placement in the setting of negative work up for sudden cardiac arrest. Clinical Discussion: Vaping-induced sudden cardiac arrest may be attributed to a reduction in cardiac repolarization reserve. Exposure to vegetable glycerin and propylene glycol, substances present in nearly all vape products, have been found to incite arrhythmias and disrupt cardiac conduction in animals. Acrolein,a byproduct of glycerin, has also been found to induce arrhythmias due to autonomic dysfunction. Increased prevalence of ventricular arrhythmias have also been noted with exposure to aerosols containing nicotine-free propylene glycol (PG).This likely stems from the impact of PG aerosols on the transient outward potassium current, which plays a significant role in early cardiac repolarization. Conclusion: The effects of inhaling vape aerosols remain not fully understood. While there is a perceived notion that nicotine-free aerosols may not be harmful, that remains unclear.Further studies should be conducted to evaluate for pro-arrhythmogenic effects and autonomic dysfunction from the various chemical substances present in vape aerosols.

Introduction: Data on clinical outcomes of percutaneous closure of iatrogenic atrial septal defect (PC-ASD) in patients undergoing transcatheter edge-to-edge repair (TEER) or mitral valve replacement (TMVR) remains limited. We used a real-world USA database to evaluate the differences in the in-hospital outcomes between both groups. Hypothesis: Is there a clinical significance for PC-ASD in patients undergoing TEER or TMVR? Methods: We used the National Inpatient Sample (2015-2020) by utilizing ICD-10 codes to identify all patients who underwent TEER or TMVR with or without PC-ASD. Multivariate logistic regression was used for adjusted outcomes (adjusted odds ratio [aOR]). Results: A total of 44,065 eligible weighted hospitalizations were included: 39,625 (89.9%) of the patients underwent TEER and 4,440 (10.1%) underwent TMVR. Rates of PC-ASD were higher in TMVR group compared to TEER group (10.7% vs. 2.0%, p<0.01). In patients who underwent TEER without PC-ASD, PC-ASD was more associated with acute heart failure (AHF) (aOR 1.42 [1.19-1.68], p<0.01) and longer hospitalizations (aOR 1.64 [1.41-1.89], p<0.01), without significant difference in inpatient mortality (aOR 0.97 [0.61-1.54], p<0.01), cardiogenic shock (aOR 1.13 [0.85-1.51], p=0.21), need for mechanical circulatory support (MCS) (aOR 0.98 [0.61-1.54], p=0.18), and stroke. Compared to patients who underwent TMVR without PC-ASD, PC-ASD was associated with higher inpatient morality (aOR 1.65 [1.13-2.4], p<0.01), need for MCS (aOR 1.91 [1.33-2.73], p<0.01) without significant difference in AHF (aOR 1.19 [0.94-1.51], p=0.18] and cardiogenic shock (aOR 0.83 [0.56-1.22], p=0.43). Remarkably, PC-ASD was less associated with stroke (aOR 0.27 [0.10-0.72], p<0.01). Conclusions: Rates of PC-ASD after TEER were lower than after TMVR and were associated with worse in-hospital mortality and need for MCS in TMVR but not in TEER. Also, PC-ASD was less associated with stroke after TMVR.