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Background: Pump exchange is an established strategy to treat LVAD‐related complications such as thrombosis, infection, and driveline failure. Pump upgrades with an exchange to newer generation devices are being performed to the advantage of the patient on long‐term support. The safety and efficacy of a repeat LVAD exchange with a concomitant upgrade to a third‐generation pump have not been reported. Methods: We performed a retrospective analysis of all consecutive patients who underwent a repeat LVAD device exchange and upgrade to HeartMate III (HMIII) at Houston Methodist Hospital between December 2018 and December 2020. Results: Five patients underwent exchange and upgrade to HMIII within the specified timeframe. Four patients had already had two prior exchanges (all HMII to HMII), and one patient had one prior exchange (HVAD to HVAD). In all cases, implantation was performed as destination therapy. The surgical exchange was performed via redo median sternotomy on full cardiopulmonary bypass. No unplanned redo surgery of the device component was required. In‐hospital mortality was 20% in this very high‐risk population. At 1‐, 3‐, and 6‐month follow‐up, all discharged patients were on HMIII support, with no major LVAD‐related adverse events reported. Conclusion: We report the feasibility and safety of a repeat pump exchange with an upgrade to HMIII in a high‐volume center. The decision for medical therapy versus surgical exchange has to be tailored to individual cases based on risk factors and clinical stability but in expert hands, even a re‐redo surgical approach grants options for good medium‐term outcomes. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses articles in the issue on topics including restrictive cardiomyopathies; amyloidosis; and transthyretin amyloid cardiomyopathy.

Closure of an atrial septal defect (ASD) may lead to a change in the function of both ventricles. Although right ventricular function typically improves, the left ventricle (LV) may behave in different ways. This has been a matter of much debate, with some authors reporting a decline in LV function after ASD closure and others reporting delayed improvement or no identifiable change. We report the case of a 41-year-old female with a large left-to-right ASD shunt (Qp:Qs 2.3:1 and shunt volume 3.6 L/min) who presented with biventricular systolic dysfunction that improved within 24 hours of ASD closure. We also attempt to explain the underlying hemodynamics responsible for LV failure and recovery in this patient. [ABSTRACT FROM AUTHOR]

Background: Atherosclerotic coronary artery disease (CAD) has long been shown to involve chronic low-grade subclinical inflammation. However, whether there is association between hematological indices assessed by complete blood count (CBC) and coronary atherosclerotic burden has not been well studied. Materials and Methods: Consecutive 868 patients without known CAD who presented with acute chest pain to emergency department and underwent coronary artery calcium (CAC) scoring evaluation by multi-detector cardiac computed tomography were included in our study. Clinical characteristics and CBC indices were compared among different CAC groups. Results: The cohort comprised 60% male with a mean age of 61 (SD = 14) years. Median Framingham risk of CAD was 4% (range 1-16%). Median CAC score was 0 (IQR 0-43). Higher CAC groups had significantly higher Framingham risk of CAD than lower CAC groups (P < 0.001). Among different CAC categories, there was no statistically significant difference in hemoglobin level (p 0.45), mean corpuscular volume (p 0.43), mean corpuscular hemoglobin (p 0.28), mean corpuscular hemoglobin volume (p 0.36), red cell distribution width (0.42), total white blood cell counts (p 0.291), neutrophil counts (p 0.352), lymphocyte counts (p 0.92), neutrophil to lymphocyte ratio (p 0.68), monocyte count (p 0.48), and platelet counts (p 0.25). Conclusion: Our study did not detect significant association between hematological indices assessed with CBC and coronary calcification in symptomatic patients without known CAD. [ABSTRACT FROM AUTHOR]

Obesity paradox has been described in various populations of coronary artery disease, mainly asymptomatic subjects. However, relationship between obesity and coronary artery calcification detected by cardiac CT in symptomatic patients has rarely been demonstrated. This study seeks to investigate whether the paradoxical relationship between obesity and coronary artery calcification exists in patients with acute chest pain. A final cohort of 1030 chest pain patients presenting at our emergency department who underwent coronary evaluation by multidetector cardiac CT were examined. With absent-to-mild coronary calcification (CAC score < 100) as a referent, multivariable analysis showed that presence of obesity (OR 0.564; 95% CI 0.395,0.806; P 0.002), body mass index (OR 0.945; 95% CI 0.920, 0.971; P < 0.001), body weight (OR 0.987; 95% CI 0.979, 0.995; P 0.001), and body surface area (OR 0.582; 95% CI 0.369, 0.920; P 0.020) were inversely associated with moderate-to-severe coronary calcification (CAC score > 100). This study extends the concept of obesity paradox to symptomatic patients undergoing coronary artery calcium score assessment. However, biological explanation(s) of this paradox remains unanswered. [ABSTRACT FROM AUTHOR]

In this review, we will highlight the role of late gadolinium enhancement, along with other strengths available by cardiac MRI, in determining the underlying etiology of various nonischemic cardiomyopathies. Furthermore, we will also emphasize how late gadolinium enhancement may serve as a novel risk stratification tool to further impact patient care. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 26-year-old woman suffering from chest pain. The patient underwent a chest X-ray which revealed a metallic density in her heart while recoverable inferior vena cava filter was placed. An overview of inferior vena cava (IVC) filter fracture with strut embolization to her interventricular septum is also provided.

Single coronary artery (SCA) is a very rare finding. Although most cases of SCA are found incidentally on coronary angiography, it can potentially lead to different clinical repercussions.1, 2 Herein we describe a patient with SCA who had unstable angina with subsequent sudden cardiac arrest, and we provide a brief review of the recent literature. [ABSTRACT FROM AUTHOR]

Background: Hemocompatibility‐related adverse events (HRAE) occur commonly in patients with left ventricular assist devices (LVADs) and add to morbidity and mortality. It is unclear whether the outflow graft orientation can impact flow conditions leading to HRAE. This study presents a simulation‐based approach using exact patient anatomy from medical images to investigate the influence of outflow cannula orientation in modulating flow conditions leading to HRAEs. Methods: A 3D model of a proximal aorta and outflow graft was reconstructed from a computed tomography (CT) scan of an LVAD patient and virtually modified to model multiple cannula orientations (n = 10) by varying polar (cranio‐caudal) (n = 5) and off‐set (anterior–posterior) (n = 2) angles. Time‐dependent computational flow simulations were then performed for each anatomical orientation. Qualitative and quantitative hemodynamics metrics of thrombogenicity including time‐averaged wall shear stress (TAWSS), oscillatory shear index (OSI), endothelial cell platelet activation potential (ECAP), particle residence time (PRT), and platelet activation potential (PLAP) were analyzed. Results: Within the simulations performed, endothelial cell activation potential (ECAP) and particle residence time (PRT) were found to be lowest with a polar angle of 85°, regardless of offset angle. However, polar angles that produced parameters at levels least associated with thrombosis varied when the offset angle was changed from 0° to 12°. For offset angles of 0° and 12° respectively, flow shear was lowest at 65° and 75°, time averaged wall shear stress (TAWSS) was highest at 85° and 35°, and platelet activation potential (PLAP) was lowest at 65° and 45°. Conclusion: This study suggests that computational fluid dynamic modeling based on patient‐specific anatomy can be a powerful analytical tool when identifying optimal positioning of an LVAD. Contrary to previous work, our findings suggest that there may be an "ideal" outflow cannula for each individual patient based on a CFD‐based hemocompatibility profile. [ABSTRACT FROM AUTHOR]

Background: Desensitization is one of the strategies to reduce antibodies and facilitate heart transplantation in highly sensitized patients. We describe our center's desensitization experience with combination of plasma cell (PC) depletion therapy (with proteasome inhibitor or daratumumab) and costimulation blockade (with belatacept). Methods: We reviewed five highly sensitized patients who underwent desensitization therapy with plasma cell depletion and costimulation blockade. We evaluated the response to therapy by measuring the changes in cPRA, average MFI, and number of positive beads > 5000MFI. Results: Five patients, mean age of 56 (37‐66) years with average cPRA of 98% at 5000 MFI underwent desensitization therapy. After desensitization, mean cPRA decreased from 98% to 70% (p =.09), average number of beads > 5000 MFI decreased from 59 to 37 (p =.15), and average MFI of beads > 5000 MFI decreased from 16713 to 13074 (p =.26). Conclusion: Combined PC depletion and CoB could be a reasonable strategy for sustained reduction in antibodies in highly sensitized patients being listed for heart transplantation. [ABSTRACT FROM AUTHOR]

The article describes the case of an 82-year-old female patient who was found with a cardiac tumor using a multimodal imaging approach. It notes that findings from chest computed tomography (CT) indicate a mass that extended from the right atrium to the right ventricle of the patient's heart, while assessment for suspicious tumor was conducted through cardiac magnetic resonance imaging (CMR). The case confirmed symptoms of superior vena cava syndrome caused by the tumor.

The article describes the case of a 61-year-old female patient who was diagnosed with aortic valve dysfunction caused by pannus. It notes that the patient was experiencing ventricular tachycardia and being examined through transthoracic echocardiogram and cardian multidetector computed tomography (MDCT). Information from the imaging tests confirmed that the patient's prosthetic aortic valve was not functioning due to an obstruction caused by a pannus or fibrovascular soft tissue.

Purpose: We evaluated whether serum beta-hydroxybutyrate (BHB) can identify adequate suppression of the left ventricle (LV) among patients undergoing [18F]-fluorodeoxyglucose positron emission tomography ([18F]-FDG PET) for cardiac inflammatory/infectious studies. Methods: Consecutive patients who underwent [18F]-FDG PET imaging were included. Serum BHB levels were measured in all patients on the day of imaging prior to injecting [18F]-FDG. Myocardial [18F]-FDG suppression was defined if [18F]-FDG uptake in the walls of myocardium, measured using standardized uptake values (SUV), was lower than the blood pool. The optimal threshold of BHB to identify myocardial suppression was based on receiver operating characteristics (ROC) in a random 30% sample of the study population (derivation cohort) and tested in the remaining 70% of sample (validation cohort). Results: A total of 256 images from 220 patients were included. Patients with sufficient LV suppression had significantly higher BHB levels compared to those with non-suppressed myocardium (median (IQR) BHB 0.6 (0.3–0.8) vs. 0.2 (0.2–0.3) mmol/l, p < 0.001, respectively). BHB level ≥ 0.335 mmol/l had a sensitivity of 84.90% and a specificity of 92.60% to identify adequate LV suppression in the validation cohort. All patients (100%) with BHB ≥ 0.41 mmol/l had adequate myocardial suppression compared to 29.63% of patients with BHB ≤ 0.20 mmol/l. Conclusion: Serum BHB level can be used at the point of care to identify sufficient LV suppression in patients undergoing [18F]-FDG PET cardiac inflammatory/infectious studies. Central illustration (image to the right) shows representative cases of patient images and BHB and, in the image to the left, shows the sensitivity and specificity to identify left myocardial suppression using BHB in validation group. [ABSTRACT FROM AUTHOR]

Spontaneous coronary sinus thrombosis (CST) is an extremely rare occurrence. Most cases are iatrogenic and related to right heart instrumentation, due to either central line placement or electrophysiology procedures such as pacemaker insertion that causes direct damage to the endothelial lining. The course can be insidious and may result in a fatal outcome. Diagnosis of CST is challenging, and the syndrome often goes unrecognized. However, in the current era of multimodality imaging, it is possible that this condition will be recognized in more patients. Herein, we present a patient with spontaneous coronary sinus thrombosis that was diagnosed using multimodality imaging and thereafter successfully managed. [ABSTRACT FROM AUTHOR]

Personalized risk (PR) estimates may enhance clinical decision making and risk communication by providing individualized estimates of patient outcomes. We explored stakeholder attitudes toward the utility, acceptability, usefulness and best-practices for integrating PR estimates into patient education and decision making about Left Ventricular Assist Device (LVAD). As p art of a 5-year multi-institutional AHRQ project, we conducted 40 interviews with stakeholders (physicians, nurse coordinators, patients, and caregivers), analyzed using Thematic Content Analysis. All stakeholder groups voiced positive views towards integrating PR in decision making. Patients, caregivers and coordinators emphasized that PR can help to better understand a patient's condition and risks, prepare mentally and logistically for likely outcomes, and meaningfully engage in decision making. Physicians felt it can improve their decision making by enhancing insight into outcomes, enhance tailored pre-emptive care, increase confidence in decisions, and reduce bias and subjectivity. All stakeholder groups also raised concerns about accuracy, representativeness and relevance of algorithms; predictive uncertainty; utility in relation to physician's expertise; potential negative reactions among patients; and overreliance. Stakeholders are optimistic about integrating PR into clinical decision making, but acceptability depends on prospectively demonstrating accuracy, relevance and evidence that benefits of PR outweigh potential negative impacts on decision making quality. • Patients prefer to receive personalized risk information over generalized risk information provided it is accurate. • Uptake of personalized risk hinges on prospectively demonstrating accuracy and relevance. • Clinicians hope personalized risk outputs may improve patient-physician communication. • Some stakeholders expressed concern over informational overload and emotional burden. [ABSTRACT FROM AUTHOR]

Background: Hypogammaglobulinemia (HGG) is a complication of solid organ transplantation leading to increased risk of infections. Intravenous immunoglobulin G (IVIG) replacement in patients with HGG may be able to reduce risk and morbidity associated with infection; however, there is scarce data about IVIG in mild to moderate HGG (IgG 400–700 mg/dl) and heart transplant recipients. Methods: A single center, retrospective study was performed in heart transplant recipients with mild (IgG 500–700 mg/dl) to moderate (IgG 400–499 mg/dl) HGG in the presence of an infection. Results: Forty‐two patients were included in this study; 19 patients (45.2%) received IVIG and 23 (54.8%) patients did not. Patients in the IVIG group received on average one dose of IVIG at 0.5 g/kg. No differences in incidence of new infection at 3 months (26.3% vs. 17.4%; P =.71) and 6 months (42.1% vs. 34.8%; P =.63) were observed between the IVIG and non‐IVIG groups. Infections based on mild or moderate HGG also had no differences at 3 and 6 months. Conclusion: Our findings suggest that a single infusion of IVIG in mild to moderate HGG may have little to no benefit in reducing incidence of new infections. Larger prospective studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

In the current era of the COVID-19 pandemic, intensive care patients with COVID-19 often develop respiratory failure and acute respiratory distress syndrome. While less frequent, acute circulatory collapse, with or without respiratory failure, has its own management challenges and nuances. Early identification of acute circulatory collapse requires appropriate imaging, particularly echocardiography, and precise diagnosis of cardiogenic shock using a Swan-Ganz catheter. Escalation to mechanical circulatory support (MCS), such as an intra-aortic balloon pump, Impella, and extracorporeal membrane oxygenation, has been useful in patients with acute circulatory collapse from COVID-19. This condition is associated with high morbidity and mortality, but early recognition of appropriate candidates for specific treatment strategies and escalation to MCS might improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Obstructive Sleep Apnea (OSA) is associated with many cardiovascular and psychiatric diseases. Day-time sleepiness is a common consequence of sleep apnea and correlates with road-traffic accidents (RTA). Pakistan has a high prevalence of factors which predispose an individual to OSA and death from RTAs are a huge burden. However there is a dearth of prevalence studies in this regard. We aim to understand local relevance of the disease and estimate the prevalence of individuals high-risk for OSA.Methods: This cross-sectional survey was conducted among 450 individuals at Aga Khan University Hospital (AKUH), which is a tertiary care teaching hospital in Pakistan. We used the BQ as our measurement tool. Based on the responses, participants were grouped into high or low-risk for OSA.Results: Our study sample size was 418 with 63.2% males. Mean age of our study population was 30.4 SD+/-12.3 years; and mean BMI was 23.2 SD+/-5 kg/m2. Out of the total sample size 24.9% reported snoring and there were twice as many males who snored as compared to females. Forty-five individuals reported that they had nodded off to sleep while driving at least once in their lifetime. On the other hand, the highest proportion of high risk individuals 47.6% was found in the age group 60 or above. The overall prevalence of individuals who were high risk for sleep apnea was 10%.Conclusion: A significant proportion of the population is at high-risk for OSA. Our study shows that despite low BMI and favorable craniofacial anatomy sleep apnea is still a locally relevant disease. Given the local relevance of OSAS, it is important to increase awareness among general population but more importantly among physicians of the developing countries, like Pakistan, about common clinical features and pertinent risk factors and complications of OSAS. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices (LVAD) cause altered flow dynamics that may result in complications such as stroke, pump thrombosis, bleeding, or aortic regurgitation. Understanding altered flow dynamics is important in order to develop more efficient and durable pump configurations. In patients with LVAD, hemodynamic assessment is limited to imaging techniques such as echocardiography which precludes detailed assessment of fluid dynamics. In this review article, we present some innovative modeling techniques that are often used in device development or for research purposes, but have not been utilized clinically. Computational fluid dynamic (CFD) modeling is based on computer simulations and particle image velocimetry (PIV) employs ex vivo models that helps study fluid characteristics such as pressure, shear stress, and velocity. Both techniques may help elaborate our understanding of complications that occur with LVAD and could be potentially used in the future to troubleshoot LVAD-related alarms. These techniques coupled with 3D printing may also allow for patient-specific device implants, lowering the risk of complications increasing device durability. [ABSTRACT FROM AUTHOR]

Background/Aims. Basal cell carcinoma (BCC) is the most common malignant tumor of the skin in humans. The diagnosis of BCC is made clinically, which can then be confirmed microscopically. Biopsy or surgical excision of the lesion provides the specimen for histopathological examination, which is the mainstay for diagnosis. Fine-needle aspiration cytology (FNAC) on the other hand is an even simpler procedure, which can provide accurate diagnosis to confirm or exclude the malignancy. Methods. Here, we present our experience on the role of FNAC in diagnosing BCC.We were able to recruit 37 patients, of which 35 had BCC. Both FNAC and biopsy were obtained and then interpreted independently of one another. Results. Cytology correlated with histopathology in all cases except for 2 in which the yield was deemed inadequate. The sensitivity and specificity of fine-needle aspiration cytology for basal cell carcinoma were 94.3% and 100%, respectively. Conclusions. We, therefore, recommend this technique for the initial evaluation of a patient with suspected BCC or in cases of recurrence. The technique is cheap, quick, less invasive, and highly accurate for the diagnosis of BCC. The limitation of the technique is low yield in some of the cases. [ABSTRACT FROM AUTHOR]

Molar pregnancies represent a significant burden of disease on the spectrum of gestational trophoblastic diseases. The incidence appears to be higher in women from South Asia. The purpose of our prospective study was to determine the incidence, presentation, and outcomes of all molar pregnancies at our institution. During the study period, there were a total of 16,625 patients admitted to our department; out of whom 85 patients were diagnosed with a molar pregnancy. Vaginal bleeding was the commonest symptom (94.2%); theca lutein cysts were noted in 39% of the cases. Suction, dilatation, and curettage were noted to be the preferred method in almost all cases; hysterectomy was done in 12 (14.1%) patients. Single-agent chemotherapy was employed in high-risk patients and was well tolerated. Mean followup for these patients was 5.7 months (range 1-24 months). None of these patients developed persistent trophoblastic disease, invasive mole, or choriocarcinoma during the follow-up period. [ABSTRACT FROM AUTHOR]