Vol 4-1 Case Report

Severe Symptomatic Bradycardia After Intravenous Immunoglobulin Infusion: A Rare Manifestation

Steven Douedi1*, Abbas Alshami1, Gina Francisco Ashforth1, Obiora Maludum2, Michael P. Carson1

1Department of Medicine, Jersey Shore University Medical Center, New Jersey, United States

2Department of Cardiology, Jersey Shore University Medical Center, New Jersey, United States

Intravenous immunoglobulins (IVIGs) are immunomodulating agents prepared using pooled plasma from thousands of human donors. These IVIGs have been used to treat a wide range of autoimmune, infectious, and idiopathic diseases. Their use in idiopathic thrombocytopenic purpura (ITP) was first described in 1981 and was found to be an effective alternative to splenectomy. The standard dose of IVIG in patients with ITP is 400 milligrams per kilogram body weight (mg/kg) daily for 5 days however recent data has shown a dose of 1 gram/kilogram/day for 2 days may be more effective. Side-effects during IVIG infusions have been reported in about 5 to 15% of patients. Cardiac related side-effects such as arrythmias, hypotension, and even myocardial infarction, being rare, have also been documented but are usually seen in patients with underlying cardiac pathologies. This article presents a 61-year-old male with no history of cardiac disease or arrhythmias who developed symptomatic bradycardia thirty minutes after intravenous immunoglobin infusion requiring multiple atropine injections and dopamine infusion over a 7-day hospitalization. The bradycardia resolved afterwards, and cardiac workup did not identify any underlying pathology.

DOI: 10.29245/2578-3025/2020/1.1185 View / Download Pdf
Vol 4-1 Case Report

Successful Transcatheter Aortic Valve Replacement After Iatrogenic Aortic Cusp Dissection After Treatment of Complex, Unprotected Left Main Bifurcation Coronary Artery Disease

Injoon Lee1*, Matthew P. Cauchi2, Jason Foerst1-3, Gary Swank1,2

1Section of Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

2Interventional Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

3Structural Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

Currently no literature exists regarding the safety and feasibility of transcatheter aortic valve replacement (TAVR) after aortic cusp dissection. Aortic dissection is a rare, albeit potentially fatal complication related to percutaneous coronary intervention, especially when dealing with heavily calcified coronary disease involving the left main. Rapid stratification of patients in need of early invasive repair versus conservative observation is crucial to patient morbidity and mortality. We present a case of an elderly female with severe aortic stenosis who underwent TAVR after complex intervention of heavily calcified multi-vessel coronary artery disease involving the left main and bifurcation with high-risk Impella protected rotational atherectomy and culotte stenting complicated by left coronary cusp dissection and was managed conservatively without long-term sequelae. This case highlights the achievability of TAVR after aortic cusp dissection that was treated with conservative methods.

DOI: 10.29245/2578-3025/2020/1.1183 View / Download Pdf
Vol 4-1 Case Report

Arterial Pandemonium: A Case Report of Pan-Aortic Dissection Masquerading as an Inferior Myocardial Infarction, Stroke and Bilateral Lower Extremity Paraplegia

Injoon Lee1*, Matthew P. Cauchi1, Amitabh Parashar2

1Virginia Tech-Carilion Clinic School of Medicine, Department of General Cardiovascular Disease, Roanoke, VA, USA

2Salem Veterans Affairs Medical Center, Department of Cardiology, Salem VA, USA

Background: Identifying and treating ST-elevation myocardial infarction (STEMI) in a timely manner is crucial in reducing the patient’s morbidity and mortality. However, sometimes STEMI can be caused by other pathologies such as aortic/coronary dissection, thromboembolism, septic emboli, or trauma. We present a case of a pan-aortic dissection (AD) with multi-system organ failure and shock presenting as anterior spinal cord syndrome, inferior myocardial infarction and stroke.

Case Presentation: A 62-year old woman with history of tobacco abuse and depression, presented to the Emergency Department (ED) for altered mental status. The patient was initially found outside of her home, unresponsive and bradycardic, with subsequent 12-lead electrocardiogram (EKG) demonstrating an inferior STEMI with right ventricle (RV) involvement and presumed cardiogenic shock. In the ED, the patient was awake with intermittent, though profound aphasia, as well as near complete loss of motor and sensory function in her lower extremities. She remained hypotensive and had weak peripheral pulses bilaterally in the upper and lower extremities. Emergent brain imaging was negative for ischemia, but chest imaging revealed circumferential mural thrombus extending from the aortic root into the descending aorta consistent with pan-AD and was taken urgently to the operating suite. Unfortunately, the patient died before surgical intervention could be performed.

Conclusion: This case report highlights a rare case of STEMI, stroke, cardiogenic shock and ultimately death caused by pan-AD. Timely identifying the underlying pathology in patients who present with more than typical STEMI symptoms is essential in providing potential lifesaving therapy.

• Aortic dissection symptoms can present with cardiovascular & neurological symptoms, end-organ compromise along with chest and/or abdominal pain.

• Clinicians should have high degrees of suspicion when myriad of symptoms are present in hemodynamically unstable patients.

• Aortic dissection can have numerous complications including death if not properly diagnosed and treated accordingly.

• Treatments of aortic dissection differs based on its type, hemodynamic status of the patient and any signs of end organ dysfunction.

DOI: 10.29245/2578-3025/2020/1.1184 View / Download Pdf
Vol 4-1 Mini Review Article

Metabolic Modulation to Treat Cardiac Diseases: Role for Membrane Substrate Transporters

Jan F.C. Glatz*, Joost J.F.P. Luiken, Miranda Nabben

Department of Genetics & Cell Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands

There is growing recognition of the importance and multiple roles of substrate energy metabolism in both cardiac health and disease. Cardiac diseases are frequently accompanied by altered myocardial metabolism, while chronic changes in the type of myocardial substrate utilization are found to elicit cardiac contractile dysfunction. Examples are the increased glucose utilization, at the expense of fatty acids, in cardiac hypertrophy and ischemic heart failure, and the increased fatty acid utilization, at the expense of glucose, in obesity and diabetes-related cardiac dysfunction. Modulation of cardiac metabolism has emerged as a suitable therapeutic intervention in cardiac disease. Insights obtained during the past decade have revealed sarcolemmal substrate transport, facilitated by CD36 for fatty acids and by GLUT4 for glucose, to represent the main rate-governing kinetic step of substrate utilization, over-ruling intracellular sites of flux regulation. This suggests that manipulating the presence of substrate transporters in the sarcolemma may be an effective approach for metabolic modulation therapy. The present mini-review provides a short summary of the functioning of substrate transporters CD36 and GLUT4 in the heart, and discusses their application as targets for metabolic intervention.

CD36: Cluster of Differentiation 36

FABPc: Cytoplasmic Fatty Acid-Binding Protein

FABPpm: Plasma Membrane Fatty Acid-Binding Protein

FATP: Fatty Acid Transport Protein

GLUT4: Glucose Transporter-4

SR-B2: Scavenger Receptor B2

VAMP: Vesicle-Associated Membrane Protein

v-ATPase: vacuolar-type H+-ATPase

DOI: 10.29245/2578-3025/2020/1.1187 View / Download Pdf
Vol 4-1 Mini Review Article

Influence of Chronic Cardiovascular Diseases on the Severity of Imported Falciparum Malaria

Bodo Hoffmeister1*, Abner Daniel Aguilar Valdez2

1Department of Respiratory Medicine, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

2Department of Endocrinology, Clinic Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

Falciparum malaria has a unique and complex pathophysiology. While sequestration of parasitized and non-parasitized erythrocytes leads to a progressive obstruction of the microcirculation, a marked systemic inflammation with endothelial dysfunction and consecutive increase in vascular permeability develops. Furthermore, most patients with severe disease present with some degree of hypovolemia. Due to the reduction in pre-load, direct myocardial suppression and increase in after-load acute falciparum malaria exerts diverse effects on the cardiovascular system. Increasing numbers of aging tourists and immigrants with chronic co-morbidities travel to countries where falciparum malaria is endemic. Age has consistently been described as a prominent risk factor for both severe disease and death from imported falciparum malaria in several large studies. Although for long suspected age-related chronic disorders have only recently been identified as risk factors for severe disease. Herein, we review the current concepts of the impact of age-related chronic medical conditions on the severity of imported falciparum malaria.

DOI: 10.29245/2578-3025/2020/1.1188 View / Download Pdf
Vol 4-1 Mini Review Article

Digital Health: New Approaches in Hypertension Management

Jamie Kitt1, Rachael Fox2, Katherine L Tucker3*

1Radcliffe Department of Medicine (Cardiovascular Division), University of Oxford, UK

2University of Melbourne, Melbourne, Australia

3Nuffield Department of Primary Care, University of Oxford, UK

Hypertension is a key risk factor for cardiovascular disease. Globally, approximately a third of people with hypertension remain undiagnosed, and of those diagnosed, about half are not taking antihypertensive medication. The World Health Organization has estimated that globally hypertension directly or indirectly causes the deaths of at least nine million people every year.

There is a trend towards self-monitoring of blood pressure (BP), where patients are empowered to be involved in hypertension screening and diagnosis. Novel technology, including smartphones and Blue-tooth® enabled telemonitoring, are new tools that are likely to be increasingly important in hypertension management. Several studies have shown the benefit of self-monitoring of BP coupled with co-interventions (such as telemonitoring) in improving BP management. However, these new technologies must be properly assessed and clinically validated prior to widespread implementation in the general population, or within special groups. In this mini-review, we examine how technology might improve the detection and management of hypertension.

DOI: 10.29245/2578-3025/2020/1.1186 View / Download Pdf
Vol 4-1 Mini Review Article

Vaccination Against Atherosclerosis: A Brief Review and Update

Hamideh Amirfakhryan*

Faculty of Health Science, University of South Wales, UK

Vaccination against atherosclerosis as a potential effective approach has been under investigation for more than 20 years. Different antigens have been tested in animals with a great success. Lipid-related antigens like Ox-LDL, PCSK9, non-lipid related antigens like interleukins, HSPs β2GPI, DNA vaccination and whole cell vaccination are some examples of successful examinations in animals. Plant-based vaccination which has some advantages over traditional methods has been attracted the scientists´ attention recently. Despite the very substantial struggles and promising results during these years, vaccination against atherosclerosis could not be utilized for the treatment of atherosclerosis in human in part due to the lack of clinical trials to access its safety and efficacy. In fact, designing clinical trials with a sufficient number of participants together with a sufficient duration of follow up to explore the influence of vaccine on the prevention and treatment of atherosclerosis seems to be an imperative requisiteness. It looks investing on clinical trials must be a priority to achieve a clear sight regarding the new, tempting, and promising strategy for vaccination against atherosclerosis.

DOI: 10.29245/2578-3025/2020/1.1190 View / Download Pdf