Faculty Bibliography

BACKGROUND:Approximately 19% of people infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) progress to severe or critical stages of the coronavirus disease 2019 (COVID-19) with a mortality rate exceeding 50%. We aimed to examine the characteristics, mortality rates, intubation rate, and length of stay (LOS) of patients hospitalized with COVID-19 disease with high oxygen requirements (critically ill). METHODS:We conducted a retrospective analysis in a single center in Brooklyn, New York. Adult hospitalized patients with confirmed COVID-19 disease and high oxygen requirements were included. We performed multivariate logistic regression analyses for statistically significant variables to reduce any confounding. RESULTS:A total of 398 patients were identified between March 19th and April 25th, 2020 who met the inclusion criteria, of which 247 (62.1%) required intubation. The overall mortality rate in our study was 57.3% (n = 228). The mean hospital LOS was 19.1 ± 17.4 days. Patients who survived to hospital discharge had a longer mean LOS compared to those who died during hospitalization (25.4 ± 22.03 days versus10.7 ± 1.74 days). In the multivariate analysis, increased age, intubation and increased lactate dehydrogenase (LDH) were each independently associated with increased odds of mortality. Diarrhea was associated with decreased mortality (OR 0.4; CI 0.16, 0.99). Obesity and use of vasopressors were each independently associated with increased intubation. CONCLUSIONS:In patients with COVID-19 disease and high oxygen requirements, advanced age, intubation, and higher LDH levels were associated with increased mortality, while diarrhea was associated with decreased mortality. Gender, diabetes, and hypertension did not have any association with mortality or length of hospital stay.

Acute pulmonary embolism (PE) is a commonly missed clinical entity. Prompt diagnosis of PE and the initiation of anticoagulation therapy is vital for the reduction of patient mortality. Recognizing initial electrocardiogram manifestations can aid rapid diagnosis and prompt management. The most common EKG findings associated with PE are sinus tachycardia, S1Q3T3 pattern, presence of T wave inversions in V1-V3 associated with the presence of right ventricular (RV) dysfunction, and right bundle branch block. These findings, while specific, are modestly sensitive and not always present. The gold standard of diagnosis is computerized tomographic angiography and ventilation and perfusion (V/Q). Here we present a patient who presented with symptoms mimicking angina with EKG changes in his stress test, prompting coronary angiography, which showed obstructive coronary artery disease requiring revascularization. Subsequently, further evaluation revealed a saddle pulmonary embolism that necessitated pulmonary thrombectomy.

Complete heart block (CHB) in a young patient is a rare phenomenon necessitating an extensive workup to identify the etiology of conduction disturbance. Radiotherapy of the thorax is a known risk factor for cardiomyopathy; however, CHB is a rare complication. Here we present a case of a 46-year-old man who presented with CHB and was found to have significant cardiac fibrosis and calcification of the mitral valve annulus. His management required a multidisciplinary and multimodality approach to be able to identify childhood radiation as the cause of cardiomyopathy and establish a personalized management strategy with cardiac resynchronization therapy defibrillator. This case highlights radiation therapy as an important cause of cardiac conduction abnormalities even decades later, and the importance of extensive search for other reversible etiologies using the multimodality approach.

BACKGROUND:We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA. METHODS:A nationwide inpatient database was queried to identify patients >18 years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups. RESULTS:We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance. CONCLUSIONS:The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.

The mortality of patients from a retroperitoneal hematoma remains high if treatment is delayed or inappropriate. Percutaneous endovascular repair of iatrogenic vascular complications is quickly becoming the treatment of choice. Here, we report a case of a 76-year-old female with a non-ST-elevation myocardial infarction, whose cardiac catheterization revealed a 70% distal left main coronary artery (LMCA) stenosis. She underwent successful rotational atherectomy and deployment of drug-eluting stents of the distal LMCA. Following percutaneous coronary intervention, she suffered acute profound hypotension and was found to have a retroperitoneal hematoma. Given the high cardiac risk for vascular surgery due to recent intervention and overall comorbidities, she was immediately taken to the cardiac catheterization laboratory and had a diagnostic angiogram, which revealed a right external iliac artery perforation that was treated with a covered stent. She tolerated the procedure well. This case highlights the importance of early diagnosis of retroperitoneal bleed, the prompt decision to take the patient to the cardiac catheterization laboratory, and potential use of intravascular interventions to ensure a successful outcome.

BACKGROUND:COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm. AIMS:To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab. METHODS:We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients. RESULTS:A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72). CONCLUSION:Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

Pacemaker or defibrillator placement is a common procedure done in more and more patients due to increased longevity and the prominence of cardiac disease. With more indications for cardiac implantable electrode devices, the devices themselves have evolved into more complex structures with more leads. The mechanical stress, risk of infection, and decreased blood flow through the superior vena cava (SVC) put patients at risk for SVC obstruction. Herein, we present a rare case of complete SVC obstruction secondary to fibrosis due to pacemaker leads which was treated with venoplasty and showed excellent long-term results. We also review the current literature on different approaches to treating SVC obstruction in this group of patients.

The incidence of mechanical valve thrombosis (MVT) is around 0.4 per 100 patient-years. Mitral valve thrombosis has a higher incidence than aortic valve thrombosis with a nearly 5-fold increase. Various factors contribute to MVT. The most common cause of valve thrombosis is poor adherence/disruption of anticoagulation therapy. Low cardiac output is known to increase the risk of prosthetic valve thrombosis. Other factors such as diabetes, hypertension, and other patient comorbidities might also play a role. Decreased flow promotes hypercoagulability. Lower pressure in the left atrium (and higher velocities in the left ventricle) can partially contribute to the higher incidence of mitral MVT versus aortic MVT. The presenting symptoms usually depend on the severity of the valve thrombosis; nonobstructive valve thrombosis patients have progressive dyspnea, signs of heart failure, and systemic embolization with strokes being the most common complication. In this article, we present a case of a middle-aged woman with a history of mitral and aortic mechanical prosthesis who presented with an ST-segment elevation myocardial infarction and pulmonary edema due to mechanical aortic valve prosthesis thrombosis. She had an isolated mechanical aortic valve prosthesis thrombosis with intact mitral valve, which, to the best of our knowledge, has not yet been described. We performed a literature review by searching PubMed and Embase using the keywords "mechanical valve," "thrombosis," "aortic," and "mitral," our search did not show similar cases.

Marijuana, derived from the Cannabis sativa plant, is the most commonly abused illicit drug in the United States. Now, more than ever, due to changing regulations, marijuana is more readily available and is known to be habitually used by millions. The neuropsychiatric effects of marijuana are well-known which include chronic fatigue syndrome and polyphagia. However, marijuana is also known to exert cardiac effects, such as tachycardia, hypotension, and hypertension. Marijuana has also been described in association with atrial fibrillation, ventricular tachycardia, and cardiac arrest. However, acute coronary syndromes, such as myocardial infarction in the setting of marijuana use, is rare. Herein, we present the case of a non-ST-elevation myocardial infarction (NSTEMI) in the setting of marijuana use in a 42-year-old African American male with no significant past medical history who presented with chest pain at rest one hour after smoking marijuana.

Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.