Sharma, Shriya

The use of temporary mechanical circulatory support in refractory heart failure cardiogenic shock (HFCS) has risen, leading to potential complications. Post-Cardiac Injury Syndrome (PCIS) from Impella insertion is rare but may result from subclavian artery manipulation and aortic irritation. We report the first case of pericarditis (PCIS) caused by Impella 5.5 insertion in an HFCS patient awaiting heart transplantation. The patient developed chest pain, tachycardia, and hypotension post-Impella insertion. Laboratory results and electrocardiograms confirmed PCIS. Treatment with Ibuprofen and Colchicine was successful. He received a heart transplant 14 days later. This case emphasizes recognizing iatrogenic pericarditis after Impella insertion and the need to avoid additional myocardial strain.

Klippel–Trenaunay (KT) syndrome and Cardiac Sarcoidosis (CS) are two distinct medical conditions that rarely coexist, each presenting unique challenges in diagnosis and management. Here, we present a rare case of a 30-year-old male with a history of KT syndrome complicated by recurrent deep vein thrombosis, who presented with symptoms of acute heart failure including shortness of breath, fatigue, dizziness, palpitations, and chest pain and was subsequently diagnosed with isolated CS. We discuss the importance of thorough clinical evaluation and multimodal diagnostic approaches in this complex scenario with overlapping symptoms and diagnostic dilemmas.

Background: The Society for Cardiovascular Angiography and Interventions (SCAI) staging system is a crucial tool for categorizing cardiogenic shock (CS) and guiding interventions. SCAI staging is traditionally static and may not capture dynamic changes. We evaluated the impact of axillary mechanical circulatory support and SCAI stage transition in patients with CS supported until heart transplantation. Methods: A retrospective study was conducted on patients with Impella support as bridge to transplant. Hemodynamic and vasoactive support parameters were collected and SCAI stage recorded at baseline and after 72 hours. Results: 36 patients were included in the analysis. The median age was 61 (52 – 68) with an EF of 19% (15-26%) (Figure 1). Before Impella placement, the distribution of patients across SCAI stages was as follows: 19 patients in SCAI B, 8 patients in SCAI C, and 9 patients in SCAI D. After 72 hours of Impella support, 7 patients initially classified as SCAI C transitioned to SCAI B with one deteriorating to SCAI D (Figure 2). Patients in SCAI D showed notable improvement, with 8 out of 9 patients transitioning to SCAI B. For patients initially SCAI B, RA changed from 10 to 11 mmHg, and PCWP decreased from 23 to 17 mmHg. The Fick CI increased from 2.53 to 3.02 L/min/m 2 (p=0.04), and the vasoactive inotropic score (VIS) decreased from 7.5-5.0 (p=0.05). In patients initially classified as SCAI C, RA pressure decreased from 13 to 8 mmHg, and PCWP reduced from 32 to 30 mmHg. The Fick CI improved from 1.79 to 2.61 L/min/m 2 (p<0.001), while the VIS decreased from 9.2 to 6.3 (p=0.004). For those initially in SCAI D, RA pressure reduced from 8 to 5 mmHg, and PCWP decreased from 27 to 18 mmHg. The Fick CI increased from 1.55 to 2.67 L/min/m 2 (p=0.002), and the VIS was notably reduced from 4.75 to 3.8 (p=0.36). All 36 patients survived to heart transplantation without major pre-transplant complications. Conclusion: SCAI stage C-E mortality ranges from 25 – 50% or worse. Implementing Impella 5.5 support reduced SCAI severity and may be associated with improved survival in HFCS. We demonstrated lower VIS after Impella 5.5 and a 100% event free survival to heart transplantation despite a 25% baseline SCAI D cohort. Larger data should be evaluated to assess this trend.

Background: International data on COVID-19 infection in immunosuppressed populations is limited. Heart transplant (OHT) recipients requiring immunotherapy are at risk for potentially increased complications with COVID-19 infection, including long-covid and oxidative stress during initial infection. The availability of vaccination and temporal trends in this population has not been well described. We report outcomes in immunosuppressed patients during the initial years of the COVID pandemic. Methods: All patients who underwent heart transplantation at Mayo Clinic in Florida were reviewed from March 2019 to October 2021. Patients were divided into two groups: those diagnosed with COVID-19 (based on a positive SARS-CoV-2 RT-PCR) and those not. A p value of 0.05 was considered significant using the Chi-squared test. Results: A total of 98 patients were reviewed. Of these, 49 were COVID-19-positive (CP), and 49 were negative (CN). The cohort was well matched, with a median age of 58 years (49 - 65) in both groups. 20 females in the CP group and 9 in the CN group. Diabetic status (p = .07), history of hypertension (p=.5), BMI (p=.41), GFR (p=.19), and ejection fraction (p=.29) were not significantly different between the two groups. Immunosuppression was not significantly different for CP or CN patients, with a median trough tacrolimus level of 7.68 vs. 8.70 (p = .26). The median time from transplant to CP was 384 days (237 - 677). The CN group’s median follow-up after transplant was 947 days (737 - 1191). CP hospitalization rate was 24% (5 Pfizer, 3 unvaccinated, 4 Moderna) with only 1 death. Hospitalized patients’ markers of inflammation were: IL6 19.2 (12-48), D-dimer 1408 (763 - 2227), and CRP 54 (20 - 90). The CP group was more vaccinated than the CN group (92% vs. 78%, p = .025). More CP patients received the Pfizer vaccine compared to Moderna (p = .018). Conclusion: We found that patients after OHT on similar immunotherapy regimens did not carry the same risk of contracting Covid-19 despite being vaccinated. CP patients were generally infected in the first 1.5 years after OHT. This may indicate an increased infection rate due to a weakened immune system or lack of bivalent boosters before 2022. Vaccine efficacy in this population should be evaluated in larger studies.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia detected in hospitalized patients. It is independently associated with an increased risk of stroke. Anti-fibrotic properties of mineralocorticoid receptor antagonists (MRA) have been proposed to modulate AF burden. Gender differences in patients with AF exist within the epidemiology and causative mechanisms to outcomes and complications. We compared men and women with known AF while treated with MRA to assess potential differences in stroke rate. Method: After IRB approval, we performed a retrospective chart review of all patients with confirmed HF and AF diagnoses. Patient data were extracted from electronic medical records. Patients with AF and HF treated with MRA were included in this study. Results: 64 patients with HF and AF treated with MRA were reviewed between January 2021 and September 2022. 34 were male, and 30 were female. Females were younger, 66 years (57 -74) compared to males, 73 years (60 - 78), p=.13. The median ejection fraction was similar among women, 42% (31 - 50) compared to men, 41% (33 - 49), p = .43. A significantly higher incidence of atrial fibrillation was found in our male group (59%) compared to the female group (30%), p=.02. There was no significant difference in MRA or anticoagulation use between male and female patients (p = .11, p = .12 respectively). More men had strokes compared to females (16% vs. 26% p = .17). Men were also more likely to be hypertensive compared to females (47% vs. 25%, p<.01). Conclusion: Men were more likely to have AF and stroke compared to females with HF on MRA therapy. Males were more likely to be hypertensive, which may relate to increased stroke rate in this patient population. Increased awareness of the gender-based prevalence of stroke rate in patients with HF and AF may allow for earlier recognition and reduction in stroke events.